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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?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
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A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make?
- A. Promote appropriate behavior during group therapy sessions.
- B. Encourage client input in the treatment plan.
- C. Communicate with the client using concrete language.
- D. Demonstrate assertive behavior.
Correct Answer: A
Rationale: The correct answer is A: Promote appropriate behavior during group therapy sessions. For a client with histrionic personality disorder, the priority intervention is to establish boundaries and promote appropriate behavior to ensure a therapeutic environment. This is crucial in managing attention-seeking behaviors and maintaining focus on the therapeutic goals. Encouraging client input in the treatment plan (B) is important but not the priority at this stage. Communicating with concrete language (C) may be helpful but does not address the immediate need for behavior management. Demonstrating assertive behavior (D) is not the priority as it may escalate the situation.
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.)
- A. Substance use disorder
- B. Age greater than 45 years old
- C. Female gender
- D. Currently married
- E. Schizophrenia
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. Substance use disorder is a known risk factor for suicide as it can lead to increased impulsivity and impaired decision-making. Age greater than 45 years old is a risk factor due to factors such as isolation, health issues, and life changes. Schizophrenia is associated with a higher risk of suicide due to the symptoms of the disorder and the impact on one's mental well-being. Choices C and D are incorrect as being female or currently married are not universal risk factors for suicide. The absence of choices F and G also indicates that they are not relevant risk factors for suicide.
A nurse is caring for a client who has schizophrenia who consistently does the opposite of what the nurse asks of him. The nurse recognizes this as which of the following alterations in behavior?
- A. Automatic obedience
- B. Waxy flexibility
- C. Negativism
- D. Impaired impulse control
Correct Answer: C
Rationale: The correct answer is C: Negativism. Negativism is a behavior where the client does the opposite of what is asked or expected. In this case, the client with schizophrenia consistently does the opposite of what the nurse asks, which aligns with negativism. Automatic obedience (A) is when a client complies without question, waxy flexibility (B) is characterized by maintaining limbs in the position they are placed in, and impaired impulse control (D) involves difficulty controlling impulses, none of which fit the scenario described.
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
- A. Recommend that the partner place the client in a long-term care facility.
- B. Suggest that the partner see a counselor to help him cope with his exhaustion.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Tell the partner to call a family meeting to get help.
Correct Answer: C
Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.
A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
- A. The sense of self among individual family members
- B. The future goals of the family
- C. The roles of family members
- D. The family's religious practices
Correct Answer: D
Rationale: The correct answer is D: The family's religious practices. When assessing sociocultural context, understanding the family's religious practices is essential as it influences beliefs, values, behaviors, and interactions within the family system. Religious practices can shape decision-making processes and coping strategies. A: The sense of self focuses on individual identity rather than the collective family system. B: Future goals pertain to the family's aspirations and plans, which are important but not directly related to sociocultural context. C: Roles of family members are significant in understanding family dynamics but do not capture the broader sociocultural influences.