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 ["B","C","D"]
Explanation
Choice A reason:
Canceling Netflix by Internet service is not relevant to Mr. Jones’ discharge planning. While managing finances and subscriptions may be part of overall life management, it does not address the immediate safety and mental health needs of Mr. Jones.
Choice B reason:
Releasing information signed for family to secure Mr. Jones’ loaded gun or having the police secure the gun if needed prior to discharge is crucial for ensuring his safety. Removing access to firearms reduces the risk of self-harm and is an important step in discharge planning for someone with suicidal ideation.
Choice C reason:
Obtaining a psychiatric provider follow-up appointment as soon as possible and evaluating for PHP (Partial Hospitalization Program) or residential treatment with the treatment team is essential. Continuity of care and appropriate follow-up are critical for managing Mr. Jones’ depression and preventing relapse.
Choice D reason:
Assisting in developing a safety plan prior to discharge that is written with phone numbers and interventions is vital. A safety plan provides Mr. Jones with clear steps to take if he feels at risk of harming himself, including contact information for crisis services and supportive individuals.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason:
Advising the patient he will have permanent memory loss is incorrect. While temporary memory loss can occur with ECT, it is not typically permanent. It is important to provide accurate information about potential side effects without causing unnecessary fear.
Choice B reason:
Authorizing MD signs off medical clearance that may require pre-op checklist to include EKG or lab work is an important consideration. Medical clearance ensures that the patient is physically fit for the procedure and helps identify any potential risks.
Choice C reason:
Signed informed consent by MD and patient and nurse follows up using “Teach Back Method” answering any further post-op or pre-op questions is essential. Informed consent ensures that the patient understands the procedure, risks, and benefits. The “Teach Back Method” confirms that the patient comprehends the information provided.
Choice D reason:
NPO after midnight and hold all meds unless specified such as a sip of water and blood pressure pill ordered by MD is a standard pre-op instruction. Fasting reduces the risk of aspiration during anesthesia, and holding medications ensures that the patient does not take anything that could interfere with the procedure.