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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Oriented to time, place and personal hygiene: This is incorrect. Orientation X3 refers to being oriented to person, place, and time, not personal hygiene.
B. Alert and oriented to person, place and time: This is correct. "Oriented X3" means that the client is aware of who they are (person), where they are (place), and what time it is (time).
C. Anxious, alert and oriented to place: This is incorrect. Orientation X3 does not specifically address anxiety or focus solely on orientation to place.
D. Awake and oriented to place: This is incorrect. Orientation X3 includes person, place, and time, not just being awake and oriented to place.
Correct Answer is C
Explanation
A. Disclose some personal information to the client: Disclosing personal information is not appropriate and may not help in building trust.
B. Wait for the client to initiate interactions with the nurse. This approach might prolong the establishment of trust and rapport.
C. Set aside short, frequent times each day to spend with the client. Regular, consistent interaction helps build trust and establish a relationship.
D. Tell the client he reminds the nurse of her father. Making personal comparisons can be inappropriate and may not be helpful in building a professional relationship.
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