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 A
Explanation
Choice A rationale:
Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
Choice B rationale:
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
Choice C rationale:
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
Choice D rationale:
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
Correct Answer is A
Explanation
Choice A rationale:
Elevating the head of the bed can help prevent intracranial pressure by promoting venous drainage from the head.
Choice B rationale:
Premature newborns need to rest and conserve energy, so excessive stimulation every 2 hours is not recommended.
Choice C rationale:
Placing the newborn in a radiant warmer helps maintain a stable body temperature, but it does not directly address intracranial pressure.
Choice D rationale:
Administering hypertonic solution is not a standard intervention for decreasing intracranial pressure in a premature newborn.
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