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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Group therapy is a valuable treatment method in mental health settings that offers several benefits. The statement "It establishes a situation where the client can relate to others and share perceptions" highlights one of the primary advantages of group therapy. In a group therapy setting, individuals with similar mental health issues come together to share their experiences, challenges, and perspectives. This process allows clients to realize that they are not alone in their struggles and fosters a sense of belonging and understanding. It can provide comfort, validation, and support as participants gain insight into their own thoughts and feelings through interactions with others.
Incorrect:
A. "It is economical since one staff member can treat many clients at once." While group therapy can be cost-effective in terms of staff resources, its primary goal is not solely based on economic considerations. The focus is on providing a therapeutic environment that promotes growth, support, and interpersonal learning for participants.
B. "It provides a forum to reinforce client teaching regarding medication administration." Although group therapy sessions may occasionally touch upon topics related to medication management, the main purpose of group therapy is not to provide medication education or reinforcement. Individual counseling or psychoeducation sessions are typically more appropriate for that specific purpose.
D. "It enables clients to see that other individuals have mental health issues." While it is true that group therapy allows individuals to witness the experiences of others with mental health issues, the purpose is not limited to simply observing that others have similar struggles. The primary goal is to create a safe space for participants to actively engage, share, and explore their own experiences in a supportive and therapeutic group setting. The focus is on personal growth, insight, and development.
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