Brian is seeking treatment for PTSD following his tour of duty in a combat zone. He reports to the assessment nurse that he has been smoking marijuana and drinking alcohol daily for the past 4 days because he just can't stand feeling depressed all the time. Which of these assessments is the nurse's highest priority?
Suicide risk assessment
Neurological assessment
Amount of current cannabis use
Marital status
The Correct Answer is A
Choice A reason: Given Brian's recent substance use and expression of not being able to tolerate depressive feelings, a suicide risk assessment is the highest priority to ensure his immediate safety.
Choice B reason: While a neurological assessment may be relevant, it is not the highest priority when there is a potential risk of suicide.
Choice C reason: Assessing the amount of current cannabis use is important but secondary to evaluating the risk of suicide.
Choice D reason: Marital status may inform social support but is not the highest priority in the context of potential self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Given Brian's recent substance use and expression of not being able to tolerate depressive feelings, a suicide risk assessment is the highest priority to ensure his immediate safety.
Choice B reason: While a neurological assessment may be relevant, it is not the highest priority when there is a potential risk of suicide.
Choice C reason: Assessing the amount of current cannabis use is important but secondary to evaluating the risk of suicide.
Choice D reason: Marital status may inform social support but is not the highest priority in the context of potential self-harm.
Correct Answer is A
Explanation
Choice A reason: This statement reflects an understanding of the need to ground perceptions in reality, which is a key step in managing paranoid personality disorder.
Choice B reason: While learning to trust others is important, it does not directly indicate that the client has learned to validate their ideas before acting.
Choice C reason: Being able to differentiate true suspicions can be part of managing the disorder, but it does not demonstrate an understanding of the need to validate ideas with others.
Choice D reason: Understanding the origins of paranoid thinking is insightful, but it does not show that the client has learned to validate their ideas before taking action.
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