A nurse is assisting with the admission assessment for a client who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?

Identifying if friends or family are available to help

Identifying the client's coping skills

Determining if the client has thoughts of self-harm

Asking the client to identify the cause of the crisis

Answer and Explanation

The Correct Answer is C

A. Identifying if friends or family are available to help: Important for support but not the immediate priority.
B. Identifying the client's coping skills: Important for long-term care but not the immediate priority.
C. Determining if the client has thoughts of self-harm: Correct. Assessing for self-harm or suicidal ideation is crucial for immediate safety.
D. Asking the client to identify the cause of the crisis: Important for understanding the crisis but not the immediate priority.

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Correct Answer is D

Explanation

A. Guided imagery: Guided imagery involves creating mental images to promote relaxation, not applicable here.
B. Orientation to reality: Reality orientation involves correcting misperceptions about time, place, and person, not used in this context.
C. Remotivation: Remotivation involves stimulating a client's interest in the environment and is not applicable here.
D. Validation: Correct. Validation acknowledges the client's feelings and emotions, supporting their sense of reality.

A. Thought content B. Thought process C. Memory D. Sensorium

Correct Answer is B

Explanation

A. Thought content: Thought content refers to the subject matter of what a person is thinking about, such as the presence of delusions or obsessions, but not necessarily whether their thoughts are logical.
B. Thought process: Thought process involves the way thoughts are organized and connected. Assessing if ideas are logical and make sense pertains to the thought process.
C. Memory: Memory pertains to the ability to recall information, not the logical consistency of thought processes.
D. Sensorium: Sensorium relates to the state of consciousness and awareness, not the logical structure of thoughts.

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A nurse is assisting with the admission assessment for a client who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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