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Mr. Jones is a 55-year-old divorced white male who was recently fired from his job. He lives alone in an apartment, and his sister, who lives nearby, called the police when she found no food in his refrigerator, his house was in shambles, and he threatened “to shoot himself.” When the police arrived, they placed him on an involuntary hold 5150 for danger to self (DTS). In the ambulance, his blood pressure is 180/96, his pulse is 96, respirations are 20 with pulse ox at 99%, and his temperature is 98.6. He looks down and is moving around a lot in his chair.When conducting an admission assessment for Mr. Jones on the psychiatric unit, your first nursing priority is (select the best answer):

A.

“Are you taking any illegal drugs or have you been drinking?”

B.

“Can you tell me why you want to kill yourself?”

C.

Avoid direct questioning and put him in a private room away from the nurses’ station.

D.

Introduce yourself and explain procedures clearly; ask him directly, “Do you feel like harming yourself?”

Answer and Explanation

The Correct Answer is D

Choice A reason:

Asking Mr. Jones if he is taking any illegal drugs or has been drinking is important for a comprehensive assessment, but it is not the first priority. The immediate concern is to assess his current risk of self-harm and ensure his safety.

 

Choice B reason:

Asking Mr. Jones why he wants to kill himself is a direct approach, but it may not be the most effective way to establish rapport and assess his immediate risk. It is important to first build trust and ensure he feels safe and understood.

 

Choice C reason:

Avoiding direct questioning and putting Mr. Jones in a private room away from the nurses’ station is not appropriate. It is important to assess his risk of self-harm directly and ensure he is in a safe environment where he can be closely monitored.

 

Choice D reason:

Introducing yourself, explaining procedures clearly, and asking Mr. Jones directly if he feels like harming himself is the best approach. This establishes rapport, provides clarity, and allows for an immediate assessment of his risk of self-harm. It ensures that he understands the process and feels supported.


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View Related questions

Correct Answer is ["A","C","D"]

Explanation

Choice A reason:

Hopelessness with poor concentration is a common symptom of major depression. Individuals with depression often feel a pervasive sense of hopelessness and find it difficult to concentrate on tasks or make decisions.

Choice B reason:

Increased energy is not a typical symptom of major depression. In fact, individuals with depression often experience fatigue and a lack of energy. Increased energy may be more indicative of a manic episode in bipolar disorder.

Choice C reason:

Difficulty falling asleep and early morning awakening are common symptoms of major depression. Sleep disturbances, including insomnia and early morning awakening, are frequently reported by individuals with depression.

Choice D reason:

Anhedonia, or the loss of interest or pleasure in previously enjoyed activities, is a hallmark symptom of major depression. Individuals with depression often find it difficult to experience joy or satisfaction in activities they once found pleasurable.

Correct Answer is ["A","C","D"]

Explanation

Choice A reason:

“Do you feel your life is empty?” is a relevant question on the geriatric depression scale. Feelings of emptiness can indicate depression, especially in older adults who may experience significant life changes and losses.

Choice B reason:

“Are you on a low cholesterol diet?” is not a relevant question for assessing depression. This question pertains to dietary habits and cardiovascular health rather than mental health.

Choice C reason:

“Have you dropped your activities or interests?” is a pertinent question on the geriatric depression scale. A loss of interest in activities that were once enjoyable is a common symptom of depression.

Choice D reason:

“Do you feel happy most of the time?” is a relevant question on the geriatric depression scale. Assessing overall happiness helps identify depressive symptoms, as individuals with depression often report feeling unhappy or sad most of the time.

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