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 B
Explanation
Choice A reason: Supervising return demonstration follows teaching, not initial assessment; determining knowledge is first. Assuming demonstration is the first step risks ineffective education, potentially leading to misuse, critical to avoid in ensuring proper diaphragm use and contraception efficacy for female clients.
Choice B reason: Determining the client’s knowledge about diaphragm use is the first step, guiding tailored education and ensuring effective use. This assessment is critical for addressing gaps, promoting adherence, preventing contraceptive failure, and supporting informed decision-making in female clients requesting diaphragms for contraception.
Choice C reason: Teaching insertion follows assessing knowledge, which identifies educational needs. Assuming teaching is first risks overlooking client understanding, potentially leading to incorrect use, critical to prevent in ensuring effective diaphragm contraception and client safety in reproductive health care.
Choice D reason: Documenting understanding is a later step after assessing and teaching; determining knowledge is priority. Assuming documentation is first risks premature recording, potentially missing educational needs, critical to avoid in ensuring comprehensive diaphragm education and effective contraception for female clients.
Correct Answer is B
Explanation
Choice A reason: Elevating the bed to 45° increases bleeding risk at the femoral site post-catheterization; flat positioning is preferred. Assessing pulses is priority. Elevating risks hematoma, critical to avoid in ensuring vascular safety, monitoring for complications, and supporting recovery in immediate postoperative cardiac catheterization care.
Choice B reason: Assessing peripheral pulses every 15 minutes post-femoral catheterization monitors for arterial occlusion or bleeding, critical for detecting complications like hematoma or thrombosis. This ensures timely intervention, essential for vascular integrity, preventing limb ischemia, and supporting safe recovery in the immediate postoperative period.
Choice C reason: Changing the dressing 4 hours post-catheterization is premature unless soiled; initial monitoring of pulses is priority. Assuming dressing change is urgent risks disrupting the site, increasing bleeding, critical to avoid in ensuring site stability and vascular safety in immediate post-catheterization care.
Choice D reason: Flexing the right knee is contraindicated post-femoral catheterization, risking site disruption or bleeding; leg immobility is required. Assessing pulses is key. Instructing flexion risks hematoma, critical to prevent in ensuring vascular safety, monitoring complications, and supporting recovery in postoperative cardiac catheterization clients.
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