The nurse is preparing to complete an initial psychiatric assessment. What should the nurse realize is the most important part of this process?
1. Providing the DSM-5 diagnosis
2. Gathering information from the family
3. Ruling out a medical causation of symptoms
4. Evaluating the need for psychotropic medication
3. Ruling out a medical causation of symptoms
Explanation: 3. The cardinal rule in psychiatric assessment is to rule out a medical causation of symptoms. Following a thorough assessment, the healthcare provider may make a DSM-5 diagnosis. If family is present, information gathering may be helpful, but it is not the most critical part of the initial assessment. Evaluating the need for psychotropic medication is not the first step in an initial assessment.
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The nurse is caring for a child brought to the emergency department by a babysitter. The child needs an emergency appendectomy and the parents cannot be contacted. What would be the nurse's best response to this situation?
A) Have the babysitter sign the consent form even if she does not have signed papers to do so. B) Have the primary care physician for the child sign the consent form. C) Document failed attempts to obtain consent to allow emergency care without consent. D) Delay medical care until the child's next of kin can be contacted.
The nurse is planning care for a client who is experiencing confusion. Which action by the nurse ensures safety for this client?
A) Keep the windows in the client's room closed. B) Keep the side rails up on the bed when the client is with a staff member. C) Place the call bell next to the client. D) Administer ordered medication.
A recently widowed client tells the doctor that she has a great deal of discomfort in the epigastric
region. She adds "I wonder if I have an ulcer.". The diagnostic tests are negative. The nurse assesses the symptom as a. preoccupation with the deceased. b. disorganization and depression. c. early reorganization behavior. d. a normal phenomenon of mourning.
Water is the universal solvent
Indicate whether the statement is true or false