A 38-year-old female presents to urgent care. She has a 3-year-old and a 4-year-old child with her. She is frightened and badly bruised. "He'll kill us all if he knows we came here," she screams. What is the nurse's best response?

A. Initiating the early interventions yourself, as the client is too emotional

This undermines the collaborative nature of crisis intervention. Clients should be involved from the beginning where possible.

B. Introducing yourself and asking how the client wishes to be addressed

Establishing rapport, safety, and trust is foundational. Proper introduction and respectful communication create a therapeutic atmosphere.

C. Limiting the length of time allowed for the client to ventilate to avoid excessive emotional reactions

Ventilation is essential for emotional release. Setting rigid limits early may suppress important feelings and hinder the therapeutic process.

D. Assuming intimacy regarding their crisis as quickly as possible

Rushing into emotional closeness may be seen as intrusive or inappropriate. Boundaries and rapport should be developed gradually.

A. Denial:

Denial is refusing to accept reality or facts, blocking external events from awareness. The student is not denying being unprepared.

B. Anger:

Anger is an emotional response, not a defense mechanism in this context.

C. Rationalization:

Rationalization is a defense mechanism where a person justifies or excuses behaviors or outcomes to avoid the true explanation, often to preserve self-esteem.

D. Avoidance:

Avoidance involves evading a person, task, or situation altogether. The student did come to class and is not avoiding it, but explaining behavior.