A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

Suicide risk

Coping abilities

Psychiatric history

Support systems

Answer and Explanation

The Correct Answer is A

When assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious, the nurse should prioritize assessing the client's suicide risk. This is because the client's symptoms, particularly feelings of depression and anxiety, can indicate a higher risk for self-harm or suicide. Assessing suicide risk is crucial to ensure the client's safety and provide appropriate interventions if needed.

incorrect:

B. Coping abilities: While assessing coping abilities is important to understand how the client manages stress and emotional challenges, it is secondary to assessing suicide risk. Coping abilities can be explored in subsequent assessments to determine the client's resilience and available resources for support.

C. Psychiatric history: Although understanding the client's psychiatric history is relevant for comprehensive care, it may not be the most immediate concern during the admission process. Assessing suicide risk takes precedence to ensure the client's safety.

D. Support systems: While assessing the client's support systems is valuable for understanding the available network of support, it should not take priority over assessing suicide risk. The client's immediate safety and potential need for intervention require immediate attention.

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Correct Answer is A

Explanation

The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.

The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.

The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.

The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.

A. Include people who can support the client adequately. B. Include people who live in the same house as the client. C. Include people whom the client views as family. D. Include people who are related to the client by blood and marriage.

Correct Answer is C

Explanation

When planning an interview for a newly admitted client and deciding who to include, the nurse should use the method of including people whom the client views as family. It is important to consider the client's perception and definition of family, as this can vary from person to person. Family can include not only blood relatives or individuals related by marriage but also those who have significant emotional connections and provide support to the client.

Incorrect:

A. Including people who can support the client adequately: While it is essential to include individuals who can provide support to the client, support can come from various sources beyond family members. Including only those who can support the client adequately may exclude important individuals in the client's life who are not considered family but still play a significant role.

B. Including people who live in the same house with the client: While individuals living in the same house as the client may have daily interactions and involvement in the client's life, they may not necessarily be considered family by the client. It is crucial to consider the client's perception of family and include individuals based on that definition.

D. Including people who are related to the client by blood and marriage: While blood relatives and individuals related by marriage can be part of the client's family, limiting the inclusion to only these individuals may exclude others who are important to the client's support system.

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A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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