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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","B","D"]

Explanation

Choice A reason:

Improvement in activities of daily living (ADLs) and displaying hopefulness in interactions with others are positive nonverbal cues indicating that therapy and medication are effective. These improvements suggest that Edward is regaining interest in daily activities and looking forward to the future.

Choice B reason:

Being less tearful and able to discuss openly the loss of his grandfather with friends and in group settings are signs that Edward is processing his grief and benefiting from therapy. Open communication about his loss indicates emotional progress and acceptance.

Choice C reason:

Continuing to isolate is not a positive nonverbal cue. Isolation suggests that Edward is still struggling with his depressive symptoms and not fully engaging with his support system. This behavior indicates that further intervention may be needed.

Choice D reason:

Smiling appropriately and interacting with peers are positive nonverbal cues that therapy and medication are working. These behaviors show that Edward is beginning to re-engage socially and experience moments of joy and connection.

Correct Answer is A

Explanation

Choice A reason:

Yogurt is one of the foods that can interact with MAOI inhibitors like Nardil. MAOIs can cause dangerous increases in blood pressure when taken with foods containing high levels of tyramine, such as aged cheeses, yogurt, fermented foods, and certain meats. Patients on MAOIs must follow strict dietary restrictions to avoid these interactions.

Choice B reason:

Vegetable salad is generally safe for individuals taking MAOI inhibitors. Fresh vegetables do not contain high levels of tyramine and do not pose a risk of interaction with MAOIs.

Choice C reason:

Oatmeal is also safe for individuals taking MAOI inhibitors. It does not contain high levels of tyramine and is not associated with adverse interactions with these medications.

Choice D reason:

Crackers are typically safe for individuals taking MAOI inhibitors, provided they do not contain aged cheeses or other high-tyramine ingredients. Plain crackers do not pose a risk of interaction with MAOIs.

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