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 B
Explanation
Choice A reason: Restricting sodium intake is not necessary with lithium carbonate, and maintaining a consistent sodium level is important to prevent lithium toxicity.
Choice B reason: Drinking excessive fluids can dilute lithium levels in the blood, potentially leading to subtherapeutic levels and reduced efficacy of the medication.
Choice C reason: Taking medications with food can help with absorption and minimize gastrointestinal side effects, but it is not specific to lithium carbonate.
Choice D reason: Having blood drawn on schedule is important for monitoring lithium levels and ensuring safe treatment.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A: Hyperventilation
Hyperventilation is rapid breathing that usually occurs because of anxiety or panic. This leads to low levels of carbon dioxide in your blood which causes a number of symptoms. Hyperventilation in anxiety can be a tricky thing to understand. On one hand, it can feel like you're suffocating or not getting enough air. On the other hand, hyperventilation can also cause shortness of breath, chest pain, and lightheadedness.
Choice B: Irritability
Irritability is a common symptom of Generalized Anxiety Disorder (GAD). Individuals with GAD often experience severe feelings of fear and unease and report feeling restless and irritable that interfere with the quality of their life.

Choice C: Anorexia
While there is a relationship between anxiety disorders and anorexia nervosa, anorexia is not a common symptom of Generalized Anxiety Disorder (GAD). Anorexia nervosa is a separate disorder that involves a fear of gaining weight and a distorted body image.
Choice D: Insomnia
Insomnia is highly prevalent in psychiatric disorders, and it has significant implications. The anxiety that characterizes GAD often interferes with the ability to sleep and leads to insomnia. This is not unexpected. Anxiety might be viewed as an inappropriate escalation of a response called arousal.
Choice E: Fatigue
Fatigue is a common symptom of Generalized Anxiety Disorder (GAD). Individuals with GAD may feel restless and have trouble relaxing. They may also tire easily or feel tired all the time.
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