A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?
Teach the client relaxation techniques.
Confirm the client's perception of the event.
Notify the client's support person.
Help the client identify personal strengths.
The Correct Answer is B
A. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.
B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.
C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.
D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Being honest with the parents of a child about the need to report suspected abuse: This reflects the ethical principle of veracity, which involves truth-telling and providing accurate information, rather than distributive justice.
B. Accepting the decision of an older adult client to live alone in her home: This action demonstrates respect for autonomy, which is honoring a client’s right to make decisions about their own life and care, not distributive justice.
C. Keeping a promise to visit with a client who is housebound after the delivery of care: This is an example of fidelity, the ethical obligation to keep commitments and follow through on promises made to clients.
D. Ensuring that a homeless client receives preventive medical care: Distributive justice focuses on fair and equitable allocation of resources and services, particularly for vulnerable or underserved populations. Providing preventive care to a homeless client exemplifies this principle.
Correct Answer is B
Explanation
A. Instruct the client to flex the right knee every 30 min: After a femoral cardiac catheterization, the affected leg should remain straight to prevent bleeding or hematoma formation. Flexing the knee could disrupt hemostasis at the insertion site.
B. Assess the client's peripheral pulses every 15 min: Frequent monitoring of peripheral pulses ensures early detection of vascular complications such as thrombosis, occlusion, or impaired circulation in the affected limb.
C. Change the client's dressing 4 hr following the procedure: The initial dressing is typically left intact for several hours or until bleeding is controlled. Early dressing changes are unnecessary and may increase infection risk.
D. Elevate the head of the client's bed to 45°: Elevating the head of the bed can increase pressure on the femoral insertion site and risk bleeding. The client’s bed is usually kept flat or slightly elevated according to provider orders until hemostasis is confirmed.
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