NCLEX-RN Question #665: Real Exam Question with Answer & Explanation

The correct answer is B. Assess suicide potential. (A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit (B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk. (C) The a

Question

A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:

Options

AAssess level of consciousness
BAssess suicide potential
CObserve for sedation and hypotension
DOrient to her room and unit rules

Explanation

(A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit (B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk. (C) The admission assessment should include observation for sedation and hypotension, but this is not in priority over suicideassessment. (D) Orientation to room and unit rules is of low priority at this time.

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