A nurse in a community clinic is caring for a client whose partner was just killed by a drunk driver. The client states, "I have no idea how I even got here. I cannot think right now." Which of the following actions should the nurse take first?
Assist the client in prioritizing decisions that must be made.
Determine whether the client is at risk for self-harm.
Help the client to identify personal strengths he can use in a crisis situation.
Identify a support person to notify and to take the client home.
The Correct Answer is B
Choice A reason: Assisting the client in prioritizing decisions is important in crisis intervention, but it is not the first priority. Before helping the client make decisions, the nurse must ensure that the client is safe and not at risk of harming themselves. Decision-making can only be effective once immediate safety is established.
Choice B reason: Determining whether the client is at risk for self-harm is the priority because the client is in acute distress and has expressed confusion and inability to think clearly. These are red flags for potential self-harm or suicidal ideation. Safety is always the first priority in crisis situations, and assessing risk ensures that urgent interventions can be implemented if needed.
Choice C reason: Helping the client identify personal strengths is a supportive intervention that can aid in coping, but it is not the immediate priority. This step comes after ensuring that the client is safe and stable.
Choice D reason: Identifying a support person to notify and take the client home is helpful for providing external support, but it is secondary to assessing immediate risk of self-harm. Without first ensuring safety, this intervention may not adequately address the client’s urgent needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Suspected abuse must be reported immediately according to mandated reporting laws and agency guidelines. This ensures the client’s safety and initiates protective interventions.
Choice B reason: Waiting until the next visit delays action and places the client at continued risk.
Choice C reason: Family therapy may be helpful but is not appropriate until abuse is addressed and safety ensured.
Choice D reason: Increasing visits does not resolve the immediate risk of abuse. Reporting is the priority.
Correct Answer is C
Explanation
Choice A reason: Allowing free interaction worsens disruption and does not protect other clients’ rights to a therapeutic environment.
Choice B reason: Threatening restraints is inappropriate and escalates agitation. Restraints are only used as a last resort for safety, not for excessive talking.
Choice C reason: Escorting the client to her room removes her from the disruptive environment and provides a calmer space. This is the most appropriate intervention to manage manic behavior.
Choice D reason: Practicing social interaction is useful in stable phases, but during acute mania the client cannot control excessive talking. This is not appropriate at this time.
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