A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?

"Who do you talk to when you need help?"

"Are you having thoughts about harming yourself?"

"What do you usually do to cope with problems in your life?"

"How do you think this event is affecting your life right now?"

Answer and Explanation

The Correct Answer is B

The priority for the nurse is to assess the client's safety and risk of self-harm or suicide, which may increase during a situational crisis. The other questions are also important to explore, but they are not as urgent as assessing for suicidal ideation or intent.

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Correct Answer is D

Explanation

During the orientation phase, the nurse should establish a rapport with group members, set ground rules, and clarify goals and expectations. The other actions are more appropriate for the working phase of the group.

A. Give the client atropine 30 min before the procedure. B. Assist the client to ambulate for the first time following the procedure. C. Witness the client's signature on the consent for the procedure. D. Check the client's condition after the procedure.

Correct Answer is B

Explanation

A: Giving the client atropine 30 min before the procedure is a task that requires professional nursing knowledge and skill to assess the medication's necessity and potential effects, thus it cannot be delegated to an assistive personnel.
B: Assisting with ambulation is a task that can be safely delegated to an assistive personnel, as it does not require the professional judgment or skill of a nurse. The assistive personnel can help maintain the client's safety while walking after the procedure.
C: Witnessing a client's signature on the consent for the procedure is a legal responsibility and requires an understanding of the procedure's risks and benefits, which is beyond the scope of assistive personnel's responsibilities.
D: Checking the client's condition after the procedure involves assessment and interpretation of clinical data, which are responsibilities of the nurse and cannot be delegated to an assistive personnel.

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A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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