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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Observe the client's range of movement: While monitoring physical status is important, mechanical restraints restrict movement, so assessing the client’s psychological triggers and safety is higher priority to prevent further aggression.

B. Identify stressors that caused the client's aggression: Understanding and addressing the factors that led to aggressive behavior is essential while the client is in restraints. This assessment helps in developing strategies to reduce agitation and prevent future episodes.

C. Hold a critical incident debriefing about the client: Debriefing is conducted after the event to support staff and evaluate interventions. It is not performed while the client is actively restrained.

D. Maintain sensory stimulation for the client: Providing excessive sensory stimulation during restraint can increase agitation and risk of injury. The focus should be on calming the client and ensuring safety rather than maintaining stimulation.

A. "You will need to change the IV dressing site once per week." B. "You will need to warm the solution in the microwave before administration." C. "You will need to weigh the client twice per week." D. "You will need to monitor the client's electrolytes daily."

Correct Answer is D

Explanation

Rationale:

A. "You will need to change the IV dressing site once per week.": Central line dressings for TPN are typically changed every 48–72 hours for gauze or every 5–7 days for transparent dressings, or sooner if the dressing becomes damp, loose, or soiled, to reduce infection risk.

B. "You will need to warm the solution in the microwave before administration.": TPN solutions should never be microwaved due to the risk of uneven heating and nutrient degradation. They should be administered at room temperature.

C. "You will need to weigh the client twice per week.": Clients receiving TPN require daily weights to monitor fluid balance, nutritional status, and detect fluid retention or dehydration promptly. Twice-weekly measurements are insufficient for close monitoring.

D. "You will need to monitor the client's electrolytes daily.": TPN can cause rapid changes in fluid and electrolyte balance, so daily electrolyte monitoring allows timely adjustments to prevent complications such as hypo- or hypernatremia, hypokalemia, and metabolic imbalances.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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