A nurse is assisting with the admission assessment for a client who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?
Identifying if friends or family are available to help
Identifying the client's coping skills
Determining if the client has thoughts of self-harm
Asking the client to identify the cause of the crisis
The Correct Answer is C
A. Identifying if friends or family are available to help: Important for support but not the immediate priority.
B. Identifying the client's coping skills: Important for long-term care but not the immediate priority.
C. Determining if the client has thoughts of self-harm: Correct. Assessing for self-harm or suicidal ideation is crucial for immediate safety.
D. Asking the client to identify the cause of the crisis: Important for understanding the crisis but not the immediate priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Guided imagery: Guided imagery involves creating mental images to promote relaxation, not applicable here.
B. Orientation to reality: Reality orientation involves correcting misperceptions about time, place, and person, not used in this context.
C. Remotivation: Remotivation involves stimulating a client's interest in the environment and is not applicable here.
D. Validation: Correct. Validation acknowledges the client's feelings and emotions, supporting their sense of reality.
Correct Answer is B
Explanation
A. You must be devastated. This response presumes the client's feelings, which may or may not be accurate.
B. Sounds like it has been a difficult time. This response acknowledges the client’s feelings and the difficulty of their situation without making assumptions about their emotional state. It shows understanding and support, which are key components of empathetic communication.
C. When one door closes, another door opens. This response can come across as dismissive or minimizing the client's feelings.
D. I'm so sorry, no wonder you are upset. This response combines sympathy and a presumption of the client's feelings, which may not fully convey empathy.
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