A nurse in an emergency department is caring for a client following an assault. Which of the following actions should the nurse take first?

Provide information to the client about local support groups.

Ask the client how they have dealt with stress in the past.

Determine if the client is experiencing thoughts of self-harm

Schedule a follow up visit with the client's primary provider.

Answer and Explanation

The Correct Answer is C

A. Provide information to the client about local support groups: While this is helpful, it is not the first priority. The client's immediate safety and emotional well-being must be addressed first, especially to rule out any thoughts of self-harm or suicidal ideation.

B. Ask the client how they have dealt with stress in the past: While understanding past coping strategies is important, the first priority should be assessing for immediate risks, such as thoughts of self-harm, before discussing past coping mechanisms.

C. Determine if the client is experiencing thoughts of self-harm: This is the first priority. After an assault, clients are at increased risk for self-harm or suicide. The nurse must assess for these thoughts immediately to ensure the client's safety.

D. Schedule a follow-up visit with the client's primary provider: Scheduling follow-up care is important, but it is not the first step. Immediate assessment for safety, including thoughts of self-harm, should take precedence.

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Correct Answer is A

Explanation

A. Schedule the client for a morning group fitness class at the facility: Regular morning exercise promotes healthy sleep patterns by helping regulate the body's circadian rhythm. Engaging in physical activity early in the day can reduce restlessness at night.

B. Limit the client to no more than four caffeinated beverages a day: While caffeine should be limited, the most effective approach is to avoid caffeine entirely in the afternoon and evening to prevent sleep disruption, rather than just limiting it to four beverages a day.

C. Walk around the hallway with the client an hour before bedtime: Although light physical activity can promote sleep, intense exercise or walking too close to bedtime can sometimes increase alertness and make it harder for the client to fall asleep.

D. Allow the client several hours in the afternoon to take a nap: Long naps, especially in the afternoon, can disrupt the client's sleep cycle and make it more difficult for them to fall asleep at night. Limiting naps during the day is typically more helpful.

A. Partial Hospitalization Programs (PHP) B. Assertive Community Treatment C. Crisis Stabilization/Observation Units D. Intensive Outpatient Programs (IOPs)

Correct Answer is B

Explanation

A. Partial Hospitalization Programs (PHP): While PHP offers structured programs during the day, it typically requires the client to be able to attend regularly. Given that the client has no transportation, this may not be a feasible option.
B. Assertive Community Treatment (ACT): ACT is a comprehensive, community-based service designed for individuals with severe mental health disorders, such as schizoaffective disorder. It offers home visits, transportation, and 24/7 support, which would be ideal for this client.
C. Crisis Stabilization/Observation Units: These units are designed for short-term stays during a crisis but are not long-term solutions for clients with ongoing needs like those of a client with schizoaffective disorder. They are more suited for acute stabilization rather than continuous care.
D. Intensive Outpatient Programs (IOPs): IOPs require the client to attend scheduled sessions, which may be difficult without transportation. Although they provide intensive treatment, they may not fully address the need for at-home and community-based support for this client.

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