A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

Discuss the importance of confidentiality.

Identify prior coping skills.

Review community resources.

Initiate referrals.

Answer and Explanation

The Correct Answer is B

A. Discussing the importance of confidentiality is important but should not be the first action.
Addressing immediate emotional needs and coping strategies takes precedence.

B. Identifying prior coping skills helps establish a foundation for managing the current crisis. It allows the nurse to build on existing strengths and provide support tailored to the adolescents'
individual needs.

C. Reviewing community resources is valuable but should come after addressing immediate emotional needs and identifying coping skills.
D. Initiating referrals may be necessary, but it should follow the identification of coping skills and immediate emotional support.

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Correct Answer is A

Explanation

A. Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B. Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C. Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D. Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.

A. "How has this impacted your life?" B. "Are you okay with not being able to do some things you used to do?" C. "Is anyone available to assist you with your hygiene?" D. “Why do you think this has happened?"

Correct Answer is A

Explanation

A. This question assesses the client's perception of the impact of the stroke on their life, providing insight into their coping abilities and emotional response.

B. This question addresses acceptance but may not fully assess the client's coping strategies or emotional response to the stroke.
C. This question addresses practical assistance with hygiene tasks but does not directly assess coping mechanisms.
D. This question focuses on the cause of the stroke rather than the client's coping abilities or emotional response.

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A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?

Correct Answer is A

Explanation

A nurse in an emergency department is assessing a client who reports recently using cocaine.Which of the following clinical manifestations should the nurse expect?

A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client's recovery?

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A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?

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A nurse is assessing a client during a follow-up visit at a behavioral health clinic. The client reports that they have not been taking the prescribed antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?