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 ["A","B","C","E"]
Explanation
A. ABG results: pH 7.32 (acidosis), HCO₃⁻ 18 mEq/L (low), PaO₂ 68 mm Hg, SaO₂ 90%. Indicates metabolic acidosis with hypoxemia. This is a significant abnormality needing prompt attention.
B. Amylase results: Elevated amylase is a hallmark of acute pancreatitis and confirms the suspected diagnosis.
C. Temperature: Fever with pancreatitis can signal systemic inflammatory response or infection, requires provider notification.
D. Hematocrit level: 42%, within the normal range (female 38–47%, male 42–52%).
E. Pain report: Severe abdominal pain 8/10, persistent >24 hours. Pancreatitis pain requires provider management (often opioids, supportive care).
F. Glucose level: 108 mg/dL is within normal limits (70–110). It is not concerning at this time.
Correct Answer is B
Explanation
A. Document the client's level of understanding about potential adverse effects: Documentation is important but should occur after assessing the client’s knowledge and providing teaching.
B. Determine the client's knowledge about diaphragm use: Assessment is the first step in the nursing process. Understanding the client’s baseline knowledge allows the nurse to tailor teaching and identify misconceptions before providing instruction.
C. Supervise return demonstration of diaphragm use: Return demonstration evaluates learning but is only appropriate after teaching and assessment have been completed.
D. Teach the client how to insert the diaphragm: Teaching is essential but should follow assessment of the client’s current understanding to ensure the instruction is effective and appropriate.
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