A nurse is caring for a client who is experiencing a crisis. Which of the following actions should the nurse take first?
Refer the client to crisis intervention services.
Determine the client's previous methods of coping with crisis.
Discuss with the client the cause of the crisis.
Assist the client to develop strategies to overcome the crisis.
The Correct Answer is B
Choice A rationale:
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
Choice B rationale:
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
Choice C rationale:
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
Choice D rationale:
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
Choice B rationale:
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
Choice C rationale:
Rationale:
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers.
Education should provide accurate and evidence-based information to address misconceptions.
Choice D rationale:
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.
Correct Answer is ["A","B","D","E"]
Explanation
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
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