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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 B

Explanation

Choice A reason:

While some may consider tricyclic antidepressants outdated, they are still used for certain conditions, including neuropathic pain. The primary concern with their use in elderly clients is not their age but their side effect profile.

Choice B reason:

Tricyclic antidepressants, including nortriptyline, can increase cardiac side effects and urinary retention, which are significant concerns in elderly clients. These medications can cause orthostatic hypotension, arrhythmias, and exacerbate urinary retention, making them less suitable for older adults with pre-existing health conditions.

Choice C reason:

The timing of medication administration (e.g., only taken at night) is not the primary issue with tricyclic antidepressants. The concern lies in their side effects, which can be particularly problematic for elderly clients.

Choice D reason:

While the cost of medication can be a factor in treatment decisions, it is not the primary reason tricyclic antidepressants are contraindicated in elderly clients. The main concern is their potential to cause serious side effects.

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

Explanation

Choice A reason:

If Mr. Greene has memory retention and a neurological evaluation that has demonstrated understanding of how to follow the sliding scale and recognize proper dosage, use, and potential side effects of insulin, he is a candidate for self-administration. This ensures he can manage his insulin therapy safely and effectively.

Choice B reason:

If Mr. Greene states “I can do it” but has severe hand tremors, he is not a candidate for self-administration of insulin. Severe hand tremors can impair his ability to accurately draw up and administer the correct dose of insulin, increasing the risk of errors.

Choice C reason:

If Mr. Greene demonstrates the ability to self-administer insulin over a period of time successfully using the “Teach Back” method by a number of staff or visiting nurse, he is a candidate for self-administration. The “Teach Back” method confirms that he understands and can perform the procedure correctly.

Choice D reason:

If Mr. Greene no longer is actively suicidal and has hand-eye coordination that is accurate, he is a candidate for self-administration of insulin. Accurate hand-eye coordination is essential for safely drawing up and administering insulin.

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