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NurseDive Free Nursing Practice Question
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
The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. identifying the client's support systems
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
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Full Explanation
The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
Similar Questions
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
The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. identifying the client's support systems
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
Full Explanation
A. Determining if the client has psychotic thinking.
Explanation: The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
A nurse caring for a cut is who has a deep vein thrombosis and is prescribed heparin by continuous infusion at 1,200 U/hr. Ava A heparin 25,000 units in 500 mL DSW. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the mL/hr for the heparin infusion, you can use the formula:
mL/hr = (Total units required per hour) / (Units/mL in the solution)
Given:
Total units required per hour = 1,200 U/hr
Units/mL in the solution = 25,000 U / 500 mL = 50 U/mL
Plugging in the values:
mL/hr = (1,200 U/hr) / (50 U/mL)
mL/hr = 24 mL/hr (rounded to the nearest tenth)
Therefore, the nurse should set the IV pump to deliver 24 mL/hr for the heparin infusion.
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
A. Focus attention on meaningful tasks.
While the behavior may occupy the client's time and attention, the primary motivation behind OCD-related compulsions is not to engage in meaningful tasks but rather to alleviate anxiety caused by obsessive thoughts.
B. Decrease anxiety to a tolerable level.
Individuals with obsessive-compulsive disorder (OCD) often engage in compulsive behaviors, such as cleaning, organizing, or checking, as a way to reduce the anxiety caused by their obsessive thoughts. In this scenario, the client's constant picking up after others is likely a compulsive behavior that serves the purpose of decreasing their anxiety to a tolerable level. The act of tidying up may temporarily alleviate the distress caused by obsessive thoughts related to cleanliness, order, or potential harm.
C. Manipulate and control others' behaviors.
The behavior described does not inherently indicate a desire to manipulate or control others. The behavior is driven by the client's internal anxiety rather than an intention to control external factors.
D. Limit the amount of time available to interact with others.
The behavior is more closely related to managing anxiety than limiting social interactions. OCD-related behaviors are driven by the need to reduce distress, not necessarily to avoid interacting with others.
Full Explanation
While the behavior may occupy the client's time and attention, the primary motivation behind OCD-related compulsions is not to engage in meaningful tasks but rather to alleviate anxiety caused by obsessive thoughts.
B. Decrease anxiety to a tolerable level.
Explanation: Individuals with obsessive-compulsive disorder (OCD) often engage in compulsive behaviors, such as cleaning, organizing, or checking, as a way to reduce the anxiety caused by their obsessive thoughts. In this scenario, the client's constant picking up after others is likely a compulsive behavior that serves the purpose of decreasing their anxiety to a tolerable level. The act of tidying up may temporarily alleviate the distress caused by obsessive thoughts related to cleanliness, order, or potential harm.
C. Manipulate and control others' behaviors.
The behavior described does not inherently indicate a desire to manipulate or control others. The behavior is driven by the client's internal anxiety rather than an intention to control external factors.
D. Limit the amount of time available to interact with others.
The behavior is more closely related to managing anxiety than limiting social interactions. OCD-related behaviors are driven by the need to reduce distress, not necessarily to avoid interacting with others.