A nurse is assisting with the admission assessment for a client who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?
Identifying if friends or family are available to help
Identifying the client's coping skills
Determining if the client has thoughts of self-harm
Asking the client to identify the cause of the crisis
The Correct Answer is C
A. Identifying if friends or family are available to help: Important for support but not the immediate priority.
B. Identifying the client's coping skills: Important for long-term care but not the immediate priority.
C. Determining if the client has thoughts of self-harm: Correct. Assessing for self-harm or suicidal ideation is crucial for immediate safety.
D. Asking the client to identify the cause of the crisis: Important for understanding the crisis but not the immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Severe: Severe anxiety includes difficulty focusing and physical symptoms but does not typically involve the ability to communicate effectively.
B. Mild: Mild anxiety may include slight nervousness but not the described behaviors.
C. Panic: Panic anxiety involves a complete inability to communicate and can include a sense of impending doom.
D. Moderate: Moderate anxiety can include increased speech rate and loudness, along with repetitive statements. While the client is exhibiting signs of distress, the symptoms described don't quite reach the intensity typically associated with severe anxiety.
Correct Answer is A
Explanation
A. Transference: Transference occurs when a client projects feelings about someone from their past onto the therapist or nurse. The client’s feelings about the nurse being similar to their mother fit this description.
B. Confrontation: Confrontation involves addressing discrepancies or issues directly, which is not the focus here. The situation described is about the client’s feelings towards the nurse.
C. Countertransference: Countertransference occurs when a nurse or therapist has emotional reactions based on their own past experiences, not the client’s feelings about the nurse.
D. Incongruence: Incongruence refers to a mismatch between a person's experiences and their self-concept. The situation described involves the client's feelings toward the nurse rather than incongruence.
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