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 B
Explanation
Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.
Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.
Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.
Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.
Correct Answer is D
Explanation
Choice A reason: Bed rest for 24 hours post-surgery increases stasis, risking thrombosis; range-of-motion exercises promote circulation. Assuming bed rest is correct risks complications, critical to avoid in ensuring active circulation and preventing venous thromboembolism in postoperative clients during recovery.
Choice B reason: Placing a pillow under knees promotes venous pooling, increasing clot risk; range-of-motion exercises are safer. Assuming pillow use is correct risks impaired circulation, critical to prevent in ensuring effective postoperative care and reducing thrombosis risk in surgical clients.
Choice C reason: Incentive spirometry prevents respiratory complications, not directly promoting circulation; range-of-motion exercises are key. Assuming spirometry aids circulation risks overlooking mobility needs, critical to avoid in ensuring proper venous return and clot prevention in postoperative clients during recovery.
Choice D reason: Range-of-motion exercises promote circulation post-surgery, preventing venous stasis and thrombosis, critical for recovery. This instruction ensures active blood flow, essential for reducing clot risk, supporting healing, and enhancing postoperative outcomes in clients across various surgical procedures.
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