A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
Determine if the client is experiencing suicidal ideation.
Identify the client's social support.
Instruct the client about coping skills.
Explore the client's perception of the event.
The Correct Answer is A
Choice A rationale:
Assessing for the client's immediate safety is the first priority in crisis intervention.
Choice B rationale:
Identifying social support is important but not the primary action in this situation.
Choice C rationale:
Instructing the client about coping skills is important, but immediate safety takes precedence.
Choice D rationale:
Exploring the client's perception of the event is valuable, but assessing for suicidality is more urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.
Choice B rationale:
Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.
Choice C rationale:
Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.
Choice D rationale:
If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.
Correct Answer is D
Explanation
Choice A rationale:
Sildenafil is typically taken as needed, not twice per day.
Choice B rationale:
Constipation is not a common adverse effect of sildenafil.
Choice C rationale:
Changing positions slowly after taking the medication is not related to sildenafil's mechanism of action.
Choice D rationale:
Sildenafil is a medication used to treat erectile dysfunction. Temporary visual changes, often described as a blue-green tinge or increased light sensitivity, are potential side effects of sildenafil due to its effect on the retinal enzyme.
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