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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Involuntary commitment is a legal process where an individual is admitted to a psychiatric facility against their will due to a perceived risk of harm to themselves or others. The primary concern in involuntary commitment is the safety and well-being of the individual and those around them.

Therefore, it is important for the nurse to inform the client's family about the reason for the involuntary commitment, emphasizing that the client's behavior poses a threat to themselves or others.

incorrect:

A. "A psychiatrist determines that the client's behavior is irrational." This statement focuses on the client's behavior being irrational, which is not the primary criteria for involuntary commitment. It is more important to emphasize the potential harm the client may cause to themselves or others.

B. "The client is unable to manage the affairs necessary for daily life." While this may be a factor contributing to the need for psychiatric treatment, it is not the specific reason for involuntary commitment. The main concern is the risk of harm associated with the client's behavior.

D. "The client has been accused of breaking the law." Involuntary commitment is not based on accusations of breaking the law. It is primarily focused on the safety and well-being of the individual and the potential risk they pose to themselves or others.

A. Explore the truth of the client's statements. B. Establish a therapeutic nurse-client relationship. C. Set behavioral limits for the client D. Show the client around the unit and introduce her to other clients.

Correct Answer is C

Explanation

The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:

A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.

B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.

D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is caring for a client who has been admitted Involuntarily for psychiatric treatment. Which of the following Information about involuntary commitment should the nurse provide the client's family?

Correct Answer is C

Explanation

A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Correct Answer is C

Explanation

A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement?

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

A client who has rheumatoid arthritis shows the nurse at her provider's office her magnetic copper bracelet and says that it helps alleviate her pain when she wears it. Which of the following responses should the nurse make?

A nurse on a mental health unit is assisting with several group therapy sessions. The nurse should include which of the following Information about using group therapy as a treatment method?

A nurse is caring for a client who begins to make sexual advances towards him. Which of the following is an appropriate statement by the nurse?

A nurse is caring for a client following the recent, sudden death of his partner. The client says, "I feel paralyzed and can't seem to cope with work or family responsibilities anymore." Which of the following types of crisis is the client demonstrating?