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?
Confirm the client’s perception of the event.
Teach the client relaxation techniques.
Help the client identify personal strengths.
Notify the client’s support person.
The Correct Answer is A
Choice A reason: Confirming the client’s perception of the crisis is the first step, establishing trust and understanding their emotional state, critical for effective intervention. This guides tailored support, essential for addressing depression in a situational crisis, ensuring therapeutic communication, and promoting coping in mental health care settings.
Choice B reason: Teaching relaxation techniques is useful but secondary to understanding the client’s crisis perception, which informs interventions. Assuming techniques are first risks misaligned support, potentially escalating distress, critical to avoid in ensuring effective crisis management for clients with depression experiencing situational stressors.
Choice C reason: Identifying strengths supports coping but follows confirming the client’s crisis perception, which sets the therapeutic foundation. Prioritizing strengths risks overlooking the client’s immediate emotional needs, potentially delaying effective intervention, critical to prevent in managing depression during a situational crisis in mental health care.
Choice D reason: Notifying a support person is secondary to understanding the client’s crisis perception, which guides initial intervention. Assuming notification is first risks bypassing the client’s perspective, potentially reducing trust, critical to avoid in ensuring client-centered care for depression in situational crisis management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A semi-sitting position for meals is impractical in a hip spica cast, risking discomfort or aspiration; turning every 2 hours prevents pressure injuries. Assuming semi-sitting is correct risks complications, critical to avoid in ensuring safe positioning and care for children in spica casts.
Choice B reason: Maintaining dependent lower extremities increases edema risk in a hip spica cast; turning every 2 hours promotes circulation. Assuming dependent positioning is correct risks swelling, critical to prevent in ensuring proper cast care and comfort for children with hip spica casts.
Choice C reason: A bedside commode is unsuitable for a hip spica cast, which covers the pelvis; bedpans are used. Turning every 2 hours is key. Assuming a commode is appropriate risks impracticality, critical to avoid in ensuring proper toileting and care in spica cast management.
Choice D reason: Turning every 2 hours prevents pressure ulcers and promotes circulation in a child with a hip spica cast, critical for skin integrity and comfort. This ensures proper cast care, reducing complications, supporting healing, and maintaining safety in pediatric orthopedic management.
Correct Answer is C
Explanation
Choice A reason: Swimming is contraindicated with a fiberglass cast, as water exposure risks skin irritation or cast damage. A hair dryer relieves itching. Allowing swimming risks infection or cast breakdown, critical to avoid in ensuring proper healing and parental education for children with arm casts.
Choice B reason: Positioning the arm in a sling at bedtime is unnecessary; elevation on pillows promotes circulation. A hair dryer addresses itching. Assuming a sling is required risks discomfort, critical to prevent in ensuring proper cast care and comfort for children post-fracture.
Choice C reason: Using a hair dryer on a cool setting safely relieves itching under a fiberglass cast, preventing skin irritation from scratching. This instruction is critical for comfort, ensuring proper cast care, supporting healing, and educating parents on safe management of a child’s arm cast post-injury.
Choice D reason: Checking finger movement every 6 hours is insufficient; frequent checks (e.g., every 2-4 hours) ensure circulation. A hair dryer is correct for itching. Assuming 6-hour checks risks delayed detection of complications, critical to avoid in ensuring safe cast care for children with fractures.
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