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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Blaming the boss for retirement reflects projection, not compensation, which involves substituting strengths for losses. Gardening competitions show compensation. Assuming blame is compensation risks misidentifying coping, potentially missing adaptive strategies, critical to avoid in supporting psychological adjustment in recently retired clients.

Choice B reason: Expressing relief about retirement reflects rationalization, not compensation, where new activities offset losses. Gardening competitions indicate compensation. Assuming relief is compensation risks misunderstanding coping, potentially overlooking adaptive behaviors, critical to prevent in assessing psychological health in clients post-retirement.

Choice C reason: Journaling about accomplishments reflects sublimation, not compensation, which involves new activities like gardening to offset retirement loss. Assuming journaling is compensation risks misinterpreting coping, potentially missing adaptive strategies, critical to avoid in supporting emotional adjustment in clients navigating retirement transitions.

Choice D reason: Entering gardening competitions post-retirement reflects compensation, substituting new achievements for lost work identity, promoting psychological adjustment. This adaptive coping is critical for mental health, supporting self-esteem, and ensuring positive adaptation, essential for assessing effective coping strategies in clients recently retired from their careers.

A. Hold a critical incident debriefing about the client. B. Observe the client’s range of movement. C. Maintain sensory stimulation for the client. D. Identify stressors that caused the client’s aggression.

Correct Answer is B

Explanation

Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.

Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.

Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.

Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

Correct Answer is D

Explanation

A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Correct Answer is B

Explanation

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