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 B
Explanation
Rationale:
A. How to change the tracheostomy dressing using clean technique: Tracheostomy dressings should be changed using sterile technique, not clean technique, to prevent infection and protect the airway. Teaching clean technique would be inappropriate.
B. How to operate the portable suction machine: Suctioning is a critical skill for maintaining airway patency and preventing respiratory complications. Teaching the partner how to operate the suction machine ensures they can assist safely at home if needed.
C. How to change the nondisposable tracheostomy tube daily: Nondisposable tracheostomy tubes are not typically changed daily; frequent changes can damage the stoma or airway. Tube changes are usually performed by trained healthcare personnel.
D. How to secure the tracheostomy tube with ties at the back of the neck: Ties should be secured in a way that avoids pressure or friction on the back of the neck, typically fastening at the sides. Focusing on back-of-neck placement could lead to skin breakdown or discomfort.
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