A nurse caring for a client is preparing to access the client’s implanted medication port (Medi port). The client states, “Every time I have to have my port accessed, I get extremely anxious, and I have heart palpitations.” Which response by the nurse would be most appropriate for the assessment stage of crisis intervention?
“Let's talk to the doctor about getting something ordered before the procedure."
“That must be overwhelming considering how often we access the port."
"Do you think you will be able to control your anxiety in the future?'
“What have you done in the past to relieve or reduce your anxiety during the procedure?"
The Correct Answer is D
This response by the nurse would be most appropriate for the assessment stage of crisis intervention because it focuses on understanding the client’s past experiences and coping mechanisms. By asking the client about what has worked for them in the past, the nurse can help the client identify and use effective strategies to manage their anxiety during the procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Confidentiality is a critical aspect of the nurse-patient relationship. However, there are specific circumstances where confidentiality must be breached to ensure the patient's safety and well-being. For instance, if a patient is expressing suicidal ideation or harm to others, the nurse has an ethical and legal obligation to report it to the treatment team to prevent harm. It is essential to explain this to the client to establish trust and clarify the limitations of confidentiality.
Option (a) is incorrect because not all information can remain confidential.
Option (b) is incorrect because not all information requires the client's approval to share.
Option (d) is incorrect because the nurse has the responsibility to disclose certain information to other healthcare professionals for the patient's benefit.
Correct Answer is A
Explanation
Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide effective care and support to the family despite the chaotic environment.
Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selflessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.
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