A tearful, anxious client comes to the clinic with the chief ...

[Zoey63294]

A tearful, anxious client comes to the clinic with the chief complaint I should be dead.. The initial
  task of the nurse conducting the assessment interview is to
 
  a. assess lethality of suicide plan.
  b. establish rapport with the client.
  c. encourage expression of anger.
  d. determine risk factors for suicide.

Question 2

A client admitted for trauma sustained while intoxicated has been hospitalized for 48 hours. He is
  shaky, irritable, and anxious and tells of having vivid nightmares for 2 nights.
 
  An hour later, the
  nurse finds the client restless and perspiring. His pulse is 130 beats/min. He shouts There are bugs
  crawling on my bed. I have got to get out of here, and begins to thrash about. The most accurate
  assessment of the situation would be the client
  a. is attempting to obtain attention by manipulating staff.
  b. may have sustained a head injury before admission.
  c. is having a recurrence of an acute psychosis.
  d. is demonstrating symptoms consistent with withdrawal delirium.

[Carliemb17]

Answer to Question 1

B
Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a
suicide plan, lethality of plan, and presence of risk factors for suicide. Option C is not an identified
intervention.

Answer to Question 2

D
Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal
delirium, a medical emergency. Option A: His behaviors are inconsistent with manipulative
attempts. Options B and C: The physical symptoms are inconsistent with both head injury and
functional psychosis.