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):
“Are you taking any illegal drugs or have you been drinking?”
“Can you tell me why you want to kill yourself?”
Avoid direct questioning and put him in a private room away from the nurses’ station.
Introduce yourself and explain procedures clearly; ask him directly, “Do you feel like harming yourself?”
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:
“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.
Correct Answer is B
Explanation
Choice A reason:
Thought content refers to the actual ideas and themes that a person expresses. It includes what the person is thinking about, such as delusions, obsessions, or preoccupations. Assessing thought content involves understanding the specific topics and beliefs the patient discusses.
Choice B reason:
Thought process refers to the way in which thoughts are organized and connected. Describing a patient’s speech as hesitant, slow, and with thought blocking indicates issues with the thought process. Thought blocking, where a person’s speech is interrupted by sudden silences, suggests difficulty in maintaining a coherent flow of ideas.
Choice C reason:
Affect refers to the observable expression of emotion. It includes the patient’s facial expressions, tone of voice, and body language. While affect can provide clues about a person’s emotional state, it does not directly relate to the organization of their thoughts.
Choice D reason:
Mood refers to the patient’s sustained emotional state, such as feeling depressed, anxious, or euphoric. While mood can influence speech patterns, the description of hesitant, slow speech with thought blocking specifically pertains to thought process rather than mood.