A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?
Teach the client relaxation techniques.
Confirm the client's perception of the event.
Notify the client's support person.
Help the client identify personal strengths.
The Correct Answer is B
A. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.
B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.
C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.
D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Limit visitors to 30 min per day: Time restrictions help reduce others’ exposure to radiation from the sealed implant. Limiting duration minimizes cumulative exposure for visitors while still allowing social interaction for the client.
B. Place the client in a semi-private room: Clients with internal radiation implants require a private room to protect others from unnecessary radiation exposure. A semi-private room increases the risk of radiation exposure to other patients and is inappropriate.
C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should avoid contact with clients receiving internal radiation entirely, as even minimal exposure could harm the fetus. The safest recommendation is to avoid visiting during treatment.
D. Wear a lead apron when providing care: A lead apron shields the nurse from radiation exposure, especially when working close to the client. This is part of the time, distance, and shielding principles for radiation safety.
E. Close the door to the client's room: Keeping the door closed helps contain radiation within the client’s room, reducing exposure to staff and visitors in nearby areas. This is a standard precaution in caring for clients with sealed implants.
Correct Answer is C
Explanation
A. Assist the family to establish a daily routine: Establishing routines can provide structure, but it is more effective after the nurse has assessed the family’s current functioning and needs following the loss.
B. Refer the family to a grief support group: Referral to support groups is beneficial, but it is not the initial step. Understanding the family’s dynamics and coping capacity should precede external referrals.
C. Determine the roles of individual family members: Assessing each member’s role and function helps the nurse understand how the family is coping and identifies areas of strength and need. This assessment guides appropriate interventions and prioritizes support.
D. Encourage the family to assign specific tasks to individual family members: Assigning tasks is part of restoring structure, but it should follow an assessment of roles and capabilities to ensure tasks are appropriate and achievable.
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