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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Related Questions
Correct Answer is C
Explanation
A. "If you don't participate in your care, you will not get better." This statement is not therapeutic as it may be perceived as judgmental or coercive. It could further discourage the client, especially if they are struggling with motivation due to depression.
B. "You can remain in bed until you feel well enough to join the group." While this response shows empathy, it might inadvertently reinforce the client's avoidance behavior and contribute to further isolation. It is generally more beneficial to encourage gradual participation rather than allowing complete withdrawal.
C. "I will assist you in getting out of bed and getting dressed." This option is appropriate because it offers support and encouragement in a gentle, non-coercive manner. Assisting the client in small steps can help them overcome inertia and begin to participate more actively in their care.
D. "The unit rules state that clients may not remain in bed." This approach is likely to be perceived as rigid and punitive. It does not address the client’s emotional state or offer support, which is crucial for someone struggling with depression.
Correct Answer is D
Explanation
A. Express sympathy for the client during interaction: Sympathy can create a sense of pity and isn't as effective as empathy, which fosters understanding.
B. Assist the client in decision-making by giving sound advice: Giving advice can undermine the client's autonomy and may not be suitable in therapeutic communication.
C. Tell the client that he should make direct eye contact when communicating verbally: Forcing direct eye contact can be intimidating for someone who is depressed.
D. Watch the client for nonverbal cues: Observing nonverbal cues can provide valuable information about the client's emotional state and needs.
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