A nurse is assisting with the admission assessment for a cilent who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?
Asking the client to identify the cause of the crisis
Determining if the client has thoughts of self-harm
Identifying if friends or family are available to help
Identifying the client's coping skills
The Correct Answer is B
Determining if the client has thoughts of self-harm: This is the priority action for the nurse in this situation. Assessing the client's risk of self-harm or suicide is crucial to determine the level of immediate intervention required. It helps identify the severity of the crisis and enables the nurse to implement appropriate measures to ensure the client's safety.
In the context of a client with generalized anxiety disorder who is exhibiting signs of distress and seeking to be taken care of, it is essential to assess for suicidal ideation or intent. Clients with mental health disorders, especially when experiencing high levels of stress, may be at an increased risk of self-harm or suicide. Therefore, it is vital for the nurse to prioritize the assessment of the client's safety and risk of self-harm in order to provide appropriate care and interventions.
Incorrect:
A- Asking the client to identify the cause of the crisis: While it is important to gather information about the cause of the crisis to understand the client's situation, it is not the nurse's priority at this moment. Assessing the client's safety and immediate risk of self-harm takes precedence.
C- Identifying if friends or family are available to help: While social support from friends and family can be valuable in managing a crisis, it is not the nurse's priority in this situation. The immediate concern is to assess the client's safety and risk of self-harm.
D-Identifying the client's coping skills: Assessing the client's coping skills is an important aspect of the overall assessment process, but it is not the priority at this moment. The nurse needs to first ensure the client's safety and address any immediate risks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
It is essential for the nurse's safety and well-being to remove themselves from a situation where the client is exhibiting verbally abusive behavior. Leaving the room allows the nurse to distance themselves from the confrontational environment and ensures their physical and emotional safety. Continuing to engage with the client may escalate the situation further and put the nurse at risk.
Incorrect:
B. Maintain eye contact until the behavior stops: Maintaining eye contact may be perceived as confrontational or provocative, which can further escalate the situation. It is advisable for the nurse to disengage from the client's presence to avoid potential harm.
C. Tell the client her behavior is disappointing: Engaging in a confrontational or judgmental response can exacerbate the client's anger or aggression. It is important for the nurse to maintain a professional and therapeutic approach while ensuring personal safety.
D. Punish the client for the behavior: Punishment is not an appropriate response to verbally abusive behavior. It can damage the nurse-client relationship and potentially worsen the client's emotional state. Promoting a supportive and therapeutic environment is key in managing challenging behaviors.
Correct Answer is D
Explanation
This response reflects the therapeutic communication technique of reflection and validation. By acknowledging the client's feelings and reflecting on them back, the nurse shows empathy and encourages further discussion. It allows the client to express their emotions and concerns, fostering a trusting and supportive relationship between the nurse and the client.
incorrect:
A. "You are in really good shape for your age." This response dismisses the client's expressed feelings of despair and does not address the underlying emotions. It fails to acknowledge the client's emotional state and may minimize their concerns.
B. "This is just a minor setback. You will be back on your feet in no time." While the intention may be to provide reassurance, this response invalidates the client's feelings of hopelessness and disregards the significance of their emotional experience. It does not address the client's statement of feeling that their time is up.
C. "The doctors are going to take good care of you. There is nothing to worry about." This response focuses solely on the medical aspect of care and may disregard the client's emotional and existential concerns. It fails to acknowledge the client's expressed feelings of their time being up and does not encourage further exploration of their emotions.
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