A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
Determining if the client has psychotic thinking
Asking the client to identify the cause of the crisis
Identifying the client's coping skills
identifying the client's support systems
The Correct Answer is A
The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
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Related Questions
Correct Answer is D
Explanation
A. "Tell me about the concerns that you have regarding your relationship."
This choice is an appropriate and open-ended question that encourages the client to express their feelings and concerns. It helps in building rapport and understanding the client's perspective.
B. "Relationship difficulties are stressful and require effort to resolve."
This choice acknowledges the challenges of relationship difficulties and conveys a supportive and empathetic attitude. It is a reasonable and non-biased statement.
C. "We could develop a plan for how to talk about this with your partner."
This choice suggests a proactive approach to address the client's concerns and promote effective communication. It is a helpful and appropriate statement.
D. "You should try to see your partner's point of view before your own."
This statement implies a biased approach, suggesting that the client should prioritize their partner's perspective over their own. While empathy and understanding are important in relationships, it's not appropriate for a healthcare professional to imply that one perspective is more important than the other. The nurse should encourage open communication and understanding from both sides rather than favoring one viewpoint.
Correct Answer is C
Explanation
A. Regression: Incorrect
Regression is a defense mechanism in which a person reverts to an earlier stage of development in response to stress or anxiety. For example, an adult might start behaving like a child when faced with a difficult situation. In this case, the student berating the teacher doesn't demonstrate a return to an earlier developmental stage, so regression is not the correct choice.
B. Conversion: Incorrect
Conversion refers to the conversion of emotional distress into physical symptoms, such as experiencing physical pain without any apparent physical cause. This mechanism is often seen in conditions like conversion disorder. The student berating the teacher is not exhibiting physical symptoms as a response to emotional distress, so conversion is not the correct choice.
C. Projection: Correct
Projection is the act of attributing one's own unacceptable feelings or thoughts to another person. In this scenario, the student is projecting their own failure onto the teacher and the course by blaming them for the failure. They are unable to accept their own role in the failure and are instead placing the blame on external factors. This aligns with the behavior described in the scenario.
D. Undoing: Incorrect
Undoing involves trying to compensate for or negate an unacceptable action or thought with a contrary action. For instance, someone who had angry thoughts might engage in excessive acts of kindness to "undo" those thoughts. The student berating the teacher is not engaging in actions to negate their negative feelings or thoughts; they are expressing their frustration directly.
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