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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.
Choice B rationale:
A high-stimulation environment could overstimulate the client and worsen delirium.
Choice C rationale:
Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.
Choice D rationale:
Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.
Correct Answer is A
Explanation
Choice A rationale:
Cardiac arrhythmia is a contraindication for electroconvulsive therapy (ECT) because ECT can cause changes in heart rate and blood pressure, which could be dangerous for someone with an existing heart condition.
Choice B rationale:
Crohn’s disease is not a contraindication for ECT. It is a chronic inflammatory bowel disease, and while it can cause significant health problems, it does not directly affect the safety or efficacy of ECT.
Choice C rationale:
Renal colic, a type of pain that can occur when a kidney stone is present, is not a contraindication for ECT. It is unrelated to the brain and nervous system and does not affect the safety or efficacy of ECT.
Choice D rationale:
Asthma is not a contraindication for ECT. While severe asthma should be well-controlled before any procedure that involves anesthesia, it is not a direct contraindication for ECT.
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