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A nurse in a mental facility receives change of shift report for 4 clients. Which of the following clients should the nurse plan to assess first?

A. A client placed in restraints due to aggressive behavior
B. A client who will be receiving her first ECT treatment today
C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
D. A newly admitted client who has a history of 4.5kg weigth loss in the past 2 months

1 Answer

5 votes

Final answer:

The nurse should first assess the client in restraints due to aggressive behavior, followed by the client with significant weight loss, the client scheduled for ECT treatment, and finally the client who received haloperidol for anxiety.

C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety

Step-by-step explanation:

The nurse in a mental facility should prioritize client assessments based on the immediacy of potential harm and the stability of their condition. When looking at the four clients described, the nurse should plan to assess the client placed in restraints due to aggressive behavior first. This situation poses an immediate risk to the client's safety and potentially to others, making it the highest priority. After that, the nurse should assess the newly admitted client who has a history of significant weight loss, as it may indicate a serious underlying condition and the need for nutritional intervention or further medical evaluation. The client who will be receiving their first ECT treatment would be the next priority to ensure they are prepped and have consented to the procedure. Finally, the client who received a PRN dose of haloperidol 2 hours ago for increased anxiety should be the last one to be checked, as they are likely to be stable following the medication administration.

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