A nurse is assisting with the admission assessment for a cilent who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?
Asking the client to identify the cause of the crisis
Determining if the client has thoughts of self-harm
Identifying if friends or family are available to help
Identifying the client's coping skills
The Correct Answer is B
Determining if the client has thoughts of self-harm: This is the priority action for the nurse in this situation. Assessing the client's risk of self-harm or suicide is crucial to determine the level of immediate intervention required. It helps identify the severity of the crisis and enables the nurse to implement appropriate measures to ensure the client's safety.
In the context of a client with generalized anxiety disorder who is exhibiting signs of distress and seeking to be taken care of, it is essential to assess for suicidal ideation or intent. Clients with mental health disorders, especially when experiencing high levels of stress, may be at an increased risk of self-harm or suicide. Therefore, it is vital for the nurse to prioritize the assessment of the client's safety and risk of self-harm in order to provide appropriate care and interventions.
Incorrect:
A- Asking the client to identify the cause of the crisis: While it is important to gather information about the cause of the crisis to understand the client's situation, it is not the nurse's priority at this moment. Assessing the client's safety and immediate risk of self-harm takes precedence.
C- Identifying if friends or family are available to help: While social support from friends and family can be valuable in managing a crisis, it is not the nurse's priority in this situation. The immediate concern is to assess the client's safety and risk of self-harm.
D-Identifying the client's coping skills: Assessing the client's coping skills is an important aspect of the overall assessment process, but it is not the priority at this moment. The nurse needs to first ensure the client's safety and address any immediate risks.
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Related Questions
Correct Answer is C
Explanation
When planning an interview for a newly admitted client and deciding who to include, the nurse should use the method of including people whom the client views as family. It is important to consider the client's perception and definition of family, as this can vary from person to person. Family can include not only blood relatives or individuals related by marriage but also those who have significant emotional connections and provide support to the client.
Incorrect:
A. Including people who can support the client adequately: While it is essential to include individuals who can provide support to the client, support can come from various sources beyond family members. Including only those who can support the client adequately may exclude important individuals in the client's life who are not considered family but still play a significant role.
B. Including people who live in the same house with the client: While individuals living in the same house as the client may have daily interactions and involvement in the client's life, they may not necessarily be considered family by the client. It is crucial to consider the client's perception of family and include individuals based on that definition.
D. Including people who are related to the client by blood and marriage: While blood relatives and individuals related by marriage can be part of the client's family, limiting the inclusion to only these individuals may exclude others who are important to the client's support system.
Correct Answer is D
Explanation
Regression is a defense mechanism that involves reverting to an earlier stage of development or behaving in a way that is characteristic of an earlier developmental level in response to stress or anxiety. It is a way for individuals to cope with overwhelming emotions or situations by retreating to a previous, more comfortable state.
In the scenario described, the client's behavior of consistently being late for appointments and ignoring household chores while expressing the need to be taken care of indicates a regressive response to stress. By relying on others to take care of their responsibilities, the client is seeking a sense of security and support, similar to how they may have relied on others in the past, such as during childhood.
Inc
A- Repression involves the unconscious blocking of unacceptable thoughts or impulses from conscious awareness.
B- Introjection is the internalization of values or qualities of another person or group.
C- Dissociation is a defense mechanism that involves detaching oneself from reality or the present moment to avoid emotional distress.
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