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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Pull the pinna of the infant's ear forward before inserting the probe: For infants, the pinna should be pulled down and back, not forward, to align the ear canal properly for accurate tympanic temperature measurement.
B. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal insertion for infants should be limited to 2.5 cm (1 in) or less to avoid rectal perforation and injury. Inserting 3.8 cm is unsafe.
C. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature measurement is safe and commonly used in infants. Placing the tip in the center of the axilla and holding the arm snugly ensures accurate contact and reading.
D. Insert the oral thermometer in front of the infant's tongue: Infants cannot reliably hold a thermometer under their tongue, making oral measurement inaccurate and unsafe due to risk of swallowing or injury.
Correct Answer is C
Explanation
A. "Polyuria can be caused by using antidepressants.": Antidepressants are more commonly associated with urinary retention or hesitancy rather than polyuria, so this statement reflects a misunderstanding of the typical causes.
B. "Polyuria can be caused by enlargement of the prostate gland.": Prostate enlargement usually causes urinary retention, difficulty initiating urination, or nocturia, rather than excessive urine output.
C. "Polyuria can be caused by drinking too much fluid.": Excessive fluid intake increases urine production, which is a common and direct cause of polyuria. This reflects an accurate understanding of one of the typical mechanisms leading to increased urine output.
D. "Polyuria can be caused by trauma to the lower urinary tract.": Trauma is more likely to result in hematuria, pain, or retention, not necessarily polyuria. This statement does not accurately reflect a common cause of excessive urination.
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