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?
Confirm the client’s perception of the event.
Teach the client relaxation techniques.
Help the client identify personal strengths.
Notify the client’s support person.
The Correct Answer is A
Choice A reason: Confirming the client’s perception of the crisis is the first step, establishing trust and understanding their emotional state, critical for effective intervention. This guides tailored support, essential for addressing depression in a situational crisis, ensuring therapeutic communication, and promoting coping in mental health care settings.
Choice B reason: Teaching relaxation techniques is useful but secondary to understanding the client’s crisis perception, which informs interventions. Assuming techniques are first risks misaligned support, potentially escalating distress, critical to avoid in ensuring effective crisis management for clients with depression experiencing situational stressors.
Choice C reason: Identifying strengths supports coping but follows confirming the client’s crisis perception, which sets the therapeutic foundation. Prioritizing strengths risks overlooking the client’s immediate emotional needs, potentially delaying effective intervention, critical to prevent in managing depression during a situational crisis in mental health care.
Choice D reason: Notifying a support person is secondary to understanding the client’s crisis perception, which guides initial intervention. Assuming notification is first risks bypassing the client’s perspective, potentially reducing trust, critical to avoid in ensuring client-centered care for depression in situational crisis management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Repositioning the NG tube is a later step; checking suction function is first, as equipment failure is a common cause of no drainage. Assuming repositioning is initial risks delaying simple fixes, potentially prolonging discomfort, critical to avoid in ensuring effective gastric decompression.
Choice B reason: Injecting air and aspirating is a troubleshooting step but follows checking suction equipment, which may resolve no drainage. Assuming air injection is first risks unnecessary intervention, potentially causing discomfort, critical to prevent in ensuring efficient NG tube management for gastric decompression.
Choice C reason: Instilling irrigation solution is a later step after confirming suction function, as equipment issues are more common. Assuming irrigation is first risks clogging or discomfort, critical to avoid in ensuring proper NG tube function and effective gastric decompression in clients with non-draining tubes.
Choice D reason: Checking suction equipment function is the first step for a non-draining NG tube, as equipment failure is a common issue, easily corrected. This ensures effective decompression, critical for preventing gastric distention, supporting client comfort, and guiding further troubleshooting in managing NG tube care.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Potential complications must be explained before consent to ensure the client understands risks like bleeding or infection, supporting informed decision-making. This is legally required, critical for ethical care, preventing misunderstandings, and ensuring the client is fully aware of colon resection’s potential adverse outcomes before signing.
Choice B reason: Possible alternative treatments, like medication or less invasive procedures, must be discussed to ensure informed consent, allowing the client to weigh options. This is essential for autonomy, critical for ethical practice, ensuring clients understand all viable paths before agreeing to a colon resection procedure.
Choice C reason: An explanation of the procedure, including what a colon resection entails, is required for informed consent, ensuring the client understands the surgical process. This promotes transparency, critical for legal and ethical standards, enabling informed decisions and reducing anxiety before signing the consent form.
Choice D reason: Expected outcomes, such as symptom relief or recovery timeline, must be provided to clarify the procedure’s benefits, ensuring informed consent. This is crucial for setting realistic expectations, supporting client autonomy, and ensuring understanding of colon resection’s purpose, critical for ethical surgical consent processes.
Choice E reason: Cost of the procedure is not typically required for informed consent, which focuses on medical risks, benefits, and alternatives. Assuming cost is necessary risks diverting focus from clinical information, potentially overwhelming the client, critical to avoid in ensuring informed consent for colon resection surgery.
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