A client who delivered a healthy newborn 4 weeks ago calls their provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more." Which of the following responses is the nurse's priority?

"Have you discussed this with your partner?"

"Do you have a friend who could help you?"

"Having a newborn must be stressful. Do you have other children?"

"Tell me about your baby. Where are they now?"

Answer and Explanation

The Correct Answer is D

A. "Have you discussed this with your partner?": While involving a partner or support system is important, this response does not immediately assess the client’s safety or potential risk of harm to self or the infant. Safety must be prioritized before exploring support strategies.

B. "Do you have a friend who could help you?": Identifying additional support is valuable, but the first step is to determine the immediate situation and whether the client or infant is in danger. This response does not address the urgent assessment of risk.

C. "Having a newborn must be stressful. Do you have other children?": Empathizing and gathering contextual information helps build rapport but does not prioritize immediate assessment of the current situation or potential danger.

D. "Tell me about your baby. Where are they now?": This response directly assesses the immediate safety of the infant and allows the nurse to determine if urgent intervention is needed. Establishing the current location and status of the baby ensures protection and prioritizes safety above all else.

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Correct Answer is B

Explanation

A. Sympathize with the client's situation: Expressing sympathy may seem supportive, but it can reinforce the client’s negative outlook rather than promote exploration of feelings or problem-solving. It may also shift focus away from objective assessment of the client’s emotional state.

B. Observe the client's nonverbal behaviors: Nonverbal cues such as facial expressions, posture, and gestures provide important information about the client’s emotional state and level of distress. Observing these behaviors helps the nurse assess mood, affect, and potential risk factors while planning appropriate interventions.

C. Remind the client that they will feel better in a few days: Offering reassurance without first understanding the client’s feelings can minimize their experience and may reduce trust. Immediate reassurance is less therapeutic than assessing and validating the client’s current emotional state.

D. Ignore the client's negative response and leave the room: Ignoring the client’s expression of distress is inappropriate and can damage rapport. It prevents the nurse from gathering essential information needed for emotional support and intervention planning.

A. The client is experiencing command hallucinations. B. The client is refusing to take their medication. C. The client is unable to initiate personal grooming tasks. D. The client is experiencing flight of ideas.

Correct Answer is A

Explanation

A. The client is experiencing command hallucinations: Command hallucinations pose an immediate risk because the client may be instructed to harm themselves or others. Ensuring safety is always the highest priority in psychiatric care, making this finding the most urgent concern for the nurse to address first.

B. The client is refusing to take their medication: Medication refusal can worsen symptoms over time, but it does not present an immediate threat to the client or others. While important to address, it is secondary to safety concerns posed by command hallucinations.

C. The client is unable to initiate personal grooming tasks: Difficulty with self-care affects the client’s hygiene and overall health but does not create an immediate risk of harm. Interventions to assist with grooming are supportive and lower priority compared to safety threats.

D. The client is experiencing flight of ideas: Flight of ideas reflects pressured speech or rapid thought patterns, which can indicate mania or acute exacerbation. While it requires monitoring and intervention, it does not present an immediate danger compared to command hallucinations.

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A client who delivered a healthy newborn 4 weeks ago calls their provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more." Which of the following responses is the nurse's priority?

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A client who delivered a healthy newborn 4 weeks ago calls their provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more." Which of the following responses is the nurse's priority?