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

Answer and Explanation

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.

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Correct Answer is C

Explanation

This response is an appropriate nursing response in this situation. It acknowledges the client's need for assistance with grocery shopping while also recognizing that shopping and personal errands are not within the nurse's job description. By suggesting to explore other resources, the nurse can help the client find alternative solutions to meet their needs. This response demonstrates a willingness to support the client and collaborate on finding appropriate assistance, while also maintaining professional boundaries and responsibilities.

A. "I won't be able to shop for you today because I have to get home to my family." This response is inappropriate because it focuses on the nurse's personal circumstances and may come across as dismissive of the client's request for help. It does not address the client's needs or offer any alternative solutions.

B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response is dismissive of the client's current situation and does not offer any practical assistance or support. It implies that the client should simply wait for their condition to improve without addressing their immediate needs.

D. "I would be happy to do whatever I can to help you." While this response may initially seem supportive, it is inappropriate because shopping and performing personal errands for the client are not within the nurse's job description. It is important for the nurse to establish professional boundaries and adhere to the responsibilities outlined in their job description.

A. Reaction-formation B. Compensation C. Projection D. Identification

Correct Answer is C

Explanation

Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else. In this case, the client is projecting their own desire to go out and have a drink onto the nurse and others involved in their care. They are attributing their own feelings to others in an attempt to avoid acknowledging or taking responsibility for their own desires.

A- Reaction-formation is a defense mechanism where an individual expresses the opposite of their true feelings or impulses.

B- Compensation is a defense mechanism where an individual tries to make up for their perceived deficiencies by excelling in another area.

D- Identification is a defense mechanism where an individual models their behavior after someone they admire.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

Correct Answer is C

Explanation

A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

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A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?

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The nurse is caring for a client who has been admitted Involuntarily for psychiatric treatment. Which of the following Information about involuntary commitment should the nurse provide the client's family?