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

Answer and Explanation

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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Correct Answer is B

Explanation

A. A client exhibiting psychotic behavior

Group therapy is generally not recommended for clients who are actively exhibiting psychotic behavior. Psychotic behavior can include hallucinations, delusions, and severe thought disturbances, which might impede the individual's ability to effectively participate and benefit from group therapy. Such clients often require more immediate and individualized attention to address their acute symptoms.

B. A client who has been taking amitriptyline for 3 months for depression

This is the correct choice. A client who has been taking amitriptyline for 3 months for depression is likely to have their symptoms more stabilized and under better control compared to acute situations. They might be at a stage where they can engage in group therapy to discuss their experiences, coping strategies, and learn from others in a similar situation.

C. A client who is experiencing alcohol intoxication

Group therapy is not appropriate for clients who are currently intoxicated, as their ability to actively participate and engage in therapeutic discussions may be compromised. Addressing the effects of alcohol intoxication and ensuring the client's safety would be a priority before considering group therapy.

D. A client admitted 12 hours ago for acute mania

Clients admitted for acute mania often require stabilization and intervention to manage their manic symptoms. In the early stages of admission, they might not be in a state conducive to group therapy. Once their acute symptoms are better controlled and they have had time to stabilize, they could potentially benefit from group therapy as part of their overall treatment plan.

A. Ask the client to create her own schedule of daily activities. B. Teach the client to use passive communication when interacting with others. C. Determine the client's need for assistance with grooming. D. Limit the client's involvement in unit activities.

Correct Answer is C

Explanation

A. Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine.

The other options do not align with best practices for caring for a client with major depressive disorder:

B. Teaching passive communication is not appropriate, as assertive communication is typically encouraged to help the client express her needs and feelings effectively.

C.Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine

D. Limiting involvement in unit activities could further isolate the client and exacerbate her symptoms. Encouraging participation and engagement is generally more beneficial.

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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?

Nursing Test Bank

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