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 A

Explanation

A. "Are you thinking of harming yourself?": Correct

This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.

B. "Do you really think your family would be better off without you?": Incorrect

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

C. "When did you first start feeling this way?": Incorrect

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

D. "Tell me what is happening right now.": Incorrect

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

Correct Answer is ["24"]

Explanation

To calculate the mL/hr for the heparin infusion, you can use the formula:

mL/hr = (Total units required per hour) / (Units/mL in the solution)

Given:

Total units required per hour = 1,200 U/hr

Units/mL in the solution = 25,000 U / 500 mL = 50 U/mL

Plugging in the values:

mL/hr = (1,200 U/hr) / (50 U/mL)

mL/hr = 24 mL/hr (rounded to the nearest tenth)

Therefore, the nurse should set the IV pump to deliver 24 mL/hr for the heparin infusion.

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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

Naxlex Comprehensive Predictor Exams

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

Correct Answer is A

Explanation

Correct Answer is ["24"]

Explanation

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