Question

A nurse on an accurate mental health facility is receiving change of shift report for for clients. Which of the following client should the nurse assess first

a.A client who does not recognize familiar peopleMY ANSWERThe nurse should assess this client to determine if this is a manifestation of a chronic disorder, such as Alzheimer's disease, or an acute change in the client's mental status. However, there is another client that the nurse should assess first.
b.A client who cannot verbalize their needsThe nurse should assess this client to determine if the client has any current needs. However, there is another client that the nurse should assess first
c.A client who is awake and disoriented at nightThe nurse should assess this client to determine if this is a manifestation of a chronic disorder, such as Alzheimer's disease, or an acute change in the client's mental status. However, there is another client that the nurse should assess first.
d.A client who is experiencing delusions of persecutionThe presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first.

Answer 1

The nurse should first assess the client experiencing delusions of persecution due to the immediate safety risk they pose. Orientation and memory are vital parts of this assessment, and in emergency situations, a rapid neurological assessment is critical.

Step-by-step explanation:

Priority in Mental Health Assessment

When prioritizing which client a nurse should assess first in a mental health facility, it is essential to address the most significant safety risk. In this scenario, the client experiencing delusions of persecution should be assessed first, as these delusions could lead to a risk of harm to themselves or others. These delusions indicate potential paranoid thoughts, where the client may believe they are being targeted or conspired against, which can escalate to dangerous behaviors.

Other clients, such as the one who does not recognize familiar people, the one who cannot verbalize their needs, and the one who is awake and disoriented at night, also require attention. However, their conditions do not seem to pose an immediate threat to safety as the client with delusions does. After addressing the most acute risk, the nurse can proceed to assess and provide care for the other clients in order of urgency, based on changes in their mental status or potential for harm.

Evaluating Mental Status

Assessing orientation and memory are crucial components of a mental status examination. This includes verifying the patient's awareness of time, place, and personal identity. The process may involve simple questions like the patient's name, the date, and their location. Furthermore, specific tasks such as the three-word recall test or asking the patient to recount the months of the year in reverse may provide additional insights into their cognitive functioning.

In emergency situations, a rapid assessment of neurological function is vital to identify any immediate threats to the patient's neurological health and determine the next steps in their care, which may include interventions like aspirin therapy or a CT scan.