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 A
Explanation
Memory loss is a known side effect of electroconvulsive therapy (ECT), particularly in the short term. It is important for the nurse to provide accurate information to the client about this
potential side effect. Assuring the client that memory loss is common and tends to improve over time can help alleviate their concerns and provide reassurance. It is important to convey that this is a temporary effect and not necessarily indicative of long-term memory problems.
The other options are not appropriate responses:
B. "You will likely experience long-term memory loss as well": This statement provides inaccurate and potentially alarming information. While some individuals may experience persistent memory issues, it is not appropriate to assume or predict long-term memory loss in every case.
C. "You should focus on how much better you feel": This response dismisses the client's concerns about memory loss and may not address their needs or worries adequately. It is important to acknowledge and validate the client's experience.
D. "I am going to notify your provider about your memory loss": While it is important for the nurse to communicate any concerning symptoms to the client's healthcare provider, simply stating this without providing further information or reassurance may increase the client's anxiety without addressing their immediate concerns about memory loss.
Correct Answer is A
Explanation
The appropriate response for the nurse in this situation is to acknowledge the partner's concern and empathize with their feelings. By stating, "It must be very difficult for you to see your wife in pain," the nurse acknowledges the partner's emotions and shows understanding and empathy. This response validates the partner's feelings and demonstrates support and compassion.
B- "We're doing everything we can to keep your wife comfortable" may be a true statement, but it does not directly address the partner's expressed wish to do something to help. It may not fully address the emotional aspect of the partner's statement.
C- "I wish there was more that I could do to relieve your wife's pain, too" is a genuine response that expresses empathy. It acknowledges the partner's desire to help and implies that the nurse shares the same sentiment. This response shows understanding and support.
D- "I'm sure your wife will begin to feel better soon" dismisses the partner's concern and does not address their expressed wish to alleviate their wife's pain. It may not fully acknowledge the partner's emotions or provide the support they need in that moment.
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