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 C

Explanation

Choice A rationale:

Psychodrama is a therapeutic approach that uses dramatic role play to help clients gain insight into their feelings and behaviors. However, it may not be the most effective for a client with antisocial personality disorder and alcohol dependency.

Choice B rationale:

Crisis intervention is a short-term therapy to stabilize a client during an acute crisis. It may not address the long-term needs of a client with antisocial personality disorder and alcohol dependency.

Choice C rationale:

Dual diagnosis treatment is designed for clients who have a mental health disorder and a substance use disorder. This would be the most appropriate for a client with antisocial personality disorder and alcohol dependency.

Choice D rationale:

Codependency support groups are typically for family members and friends of individuals with substance use disorders. They may not be the most beneficial for the client themselves.

A. Administer an antianxiety medication B. Calculate the client's score on the Hamilton Rating Scale for Anxiety. C. Explain the use of response prevention to the client. D. Discuss the benefits of relaxation exercises with the client.

Correct Answer is B

Explanation

Choice A rationale:

Administering an antianxiety medication can help manage symptoms, but it’s not the first action a nurse should take.

Choice B rationale:

Calculating the client’s score on the Hamilton Rating Scale for Anxiety is the first step in assessing the severity of the client’s anxiety.

Choice C rationale:

Explaining the use of response prevention can be beneficial, but it’s not the first action the nurse should take.

Choice D rationale:

Discussing the benefits of relaxation exercises can help manage anxiety, but it’s not the first action the nurse should take.

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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

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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?.