A nurse is reviewing the day 5 vital signs and nurse’s notes.

Exhibits

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Choice A reason:
Asking "Why do you think this has happened?" may not be the most supportive approach. This question can lead to feelings of guilt or frustration, as the client might not have an answer and could feel blamed for their condition. It is more beneficial to focus on the client's current feelings and coping mechanisms.

Choice B reason:
Asking "Are you okay with not being able to do some things you used to do?" can be perceived as insensitive. It highlights the client's limitations rather than focusing on their strengths and coping strategies. This question might make the client feel more helpless and discouraged.

Choice C reason:
Asking "Is anyone available to assist you with your hygiene?" is important for assessing the client's support system and daily needs, but it does not directly address their emotional coping. While practical support is crucial, understanding the client's emotional and psychological state is equally important.

Choice D reason:
Asking "How has this impacted your life?" is an open-ended question that allows the client to express their feelings and experiences. It helps the nurse understand the client's perspective and coping mechanisms. This question encourages the client to share their emotional journey and can provide valuable insights into their mental and emotional well-being.

Choice A reason:
When leading a crisis intervention group, especially for adolescents who have witnessed the traumatic event of a classmate's suicide, it is crucial to first identify the individuals' prior coping skills. This initial step is essential because it helps the nurse to understand the baseline coping mechanisms each adolescent has previously employed. Adolescents may have varying levels of resilience and different strategies for dealing with stress and trauma. By identifying these skills early on, the nurse can tailor the intervention to reinforce these existing skills while introducing new coping strategies. This personalized approach ensures that each adolescent's unique needs are addressed, which is particularly important in the aftermath of a suicide, where feelings of guilt, confusion, and grief can be overwhelming. Moreover, understanding their prior coping skills can help the nurse to predict potential challenges and provide targeted support to those who may be more vulnerable or at risk of negative outcomes.

Choice B reason:
Reviewing community resources is an important action but not the first one that should be taken. Community resources can provide additional support and services to the adolescents after the initial crisis intervention. These resources might include mental health services, support groups, or educational programs. However, before directing adolescents to these resources, it is essential to assess their current psychological state and coping abilities. This ensures that the resources recommended are appropriate and beneficial for each individual's specific situation.

Choice C reason:
Discussing the importance of confidentiality is a critical component of any therapeutic intervention, particularly in a group setting. It creates a safe space where adolescents feel secure to share their thoughts and feelings without fear of judgment or breach of privacy. However, this is not the first action to take. Establishing confidentiality is part of setting the ground rules for the group intervention, which typically occurs after initial assessments and once a rapport has been established.

Choice D reason:
Initiating referrals may be necessary for adolescents who require more specialized care or individual therapy. Referrals are an important part of the continuum of care and ensure that adolescents have access to the appropriate level of support. However, this action is typically taken after the initial crisis intervention session, where the nurse has had the opportunity to assess each adolescent's needs and determine who might benefit from additional services.