A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.

Reinforce teaching on the client's use of coping skills

Encourage the client to use personal support systems.

Assist with a client referral for social services.

Identify if the client has thoughts of self-harm.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.

Choice B rationale:

Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.

Choice C rationale:

Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.

Choice D rationale:

Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.

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Correct Answer is B

Explanation

Choice A rationale:

Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.

Choice B rationale:

Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.

Choice C rationale:

The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.

Choice D rationale:

Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.

A. Acknowledge an inability to control drinking B. Agree to a prescription for an alcohol use deterrent. C. Incorporate a form of spirituality into daily life. D. Form a close support network.

Correct Answer is A

Explanation

Choice A rationale:

Acknowledging an inability to control drinking is the first step in many recovery models, including the 12-step program of Alcoholics Anonymous. This step involves admitting that alcohol has taken over one’s life.

Choice B rationale:

Agreeing to a prescription for an alcohol use deterrent can be a part of the recovery process, but it is not typically the first step.

Choice C rationale:

Incorporating a form of spirituality into daily life can be a part of the recovery process for some individuals, but it is not typically the first step.

Choice D rationale:

Forming a close support network is crucial in the recovery process, but it comes after acknowledging the problem.

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A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?.

Correct Answer is B

Explanation

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

Correct Answer is A

Explanation

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A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.