NCLEX-RN · Question #555
NCLEX-RN Question #555: Real Exam Question with Answer & Explanation
The correct answer is C. Assess suicide potential.. (A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Althou
Question
Options
- AAssess the level of anxiety, coping responses, and support systems.
- BAssess the history of physical abuse.
- CAssess suicide potential.
- DAssess drug and alcohol use.
Explanation
(A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. (D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.
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