A nurse in a community clinic is caring for a client whose partner was just killed by a drunk driver. The client states, "I have no idea how I even got here. I cannot think right now." Which of the following actions should the nurse take first?
Assist the client in prioritizing decisions that must be made.
Determine whether the client is at risk for self-harm.
Help the client to identify personal strengths he can use in a crisis situation.
Identify a support person to notify and to take the client home.
The Correct Answer is B
Choice A reason: Assisting the client in prioritizing decisions is important in crisis intervention, but it is not the first priority. Before helping the client make decisions, the nurse must ensure that the client is safe and not at risk of harming themselves. Decision-making can only be effective once immediate safety is established.
Choice B reason: Determining whether the client is at risk for self-harm is the priority because the client is in acute distress and has expressed confusion and inability to think clearly. These are red flags for potential self-harm or suicidal ideation. Safety is always the first priority in crisis situations, and assessing risk ensures that urgent interventions can be implemented if needed.
Choice C reason: Helping the client identify personal strengths is a supportive intervention that can aid in coping, but it is not the immediate priority. This step comes after ensuring that the client is safe and stable.
Choice D reason: Identifying a support person to notify and take the client home is helpful for providing external support, but it is secondary to assessing immediate risk of self-harm. Without first ensuring safety, this intervention may not adequately address the client’s urgent needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Setting an extra meeting time may reinforce manipulative behavior patterns common in borderline personality disorder.
Choice B reason: Ending at the scheduled time maintains boundaries and consistency, which are crucial in managing borderline personality disorder. It teaches respect for limits and prevents manipulation.
Choice C reason: Arranging for another nurse undermines continuity of care and does not address the boundary issue.
Choice D reason: Extending the time reinforces manipulative behavior and undermines therapeutic boundaries.
Correct Answer is C
Explanation
Choice A reason: Full range of motion indicates that circulation and mobility are intact. This is not a complication.
Choice B reason: Attempting to remove the restraint shows discomfort or resistance but does not indicate a complication.
Choice C reason: A cool, pale hand suggests impaired circulation due to the restraint. This is a serious complication that requires immediate intervention to prevent tissue damage.
Choice D reason: A capillary refill of 1 second is normal and indicates adequate perfusion. This is not a complication.
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