25. A psychiatric nurse is assigned to care for multiple clients. Which client should the nurse assess first?
25. A psychiatric nurse is assigned to care for multiple clients. Which client should the nurse assess first?
. The client with auditory hallucinations, who is responding to the voices with laughter.
. The client with hallucinations, who has increased blood pressure and heart rate.
. The client with suicidal ideations, who has a nonlethal plan.
. The client with superficial self-inflicted wounds to the wrists and arms.
Test-Taking Tip
Note the key word "first." Think ABCs (circulation); the nurse's priority is based on an immediate threat to the client's safety and physiological integrity.
Content Area: Mental Health, Management of Care; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
.
Answer 1 is incorrect because the client is not in immediate danger of self-inflicted harm. Answer 2 is correct because this client has a risk of cardiovascular problems and may need medical attention. Answer 3 is incorrect because the client does not have a lethal plan. Answer 4 is incorrect because these superficial wounds are not immediately life-threatening.