A nurse is caring for a client who is experiencing a crisis. Which of the following actions should the nurse take first?
Refer the client to crisis intervention services.
Determine the client's previous methods of coping with crisis.
Discuss with the client the cause of the crisis.
Assist the client to develop strategies to overcome the crisis.
The Correct Answer is B
Choice A rationale:
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
Choice B rationale:
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
Choice C rationale:
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
Choice D rationale:
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ankle swelling can be a common symptom of pregnancy and is not necessarily indicative of a complication.
Choice B rationale:
Gums can become more sensitive during pregnancy, leading to bleeding while brushing teeth. This finding is common and not necessarily indicative of a complication.
Choice C rationale:
Constant pain in the middle of the upper abdomen can be a sign of preeclampsia, a serious pregnancy complication that requires prompt medical attention.
Choice D rationale:
Feeling dizzy when lying flat on the back (supine hypotension) can be a common discomfort during pregnancy due to pressure on the vena cava. However, it does not necessarily indicate a complication in this context.
Correct Answer is D
Explanation
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
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