A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
Determine if the client is experiencing suicidal ideation.
Identify the client's social support.
Instruct the client about coping skills.
Explore the client's perception of the event.
The Correct Answer is A
Choice A rationale:
Assessing for the client's immediate safety is the first priority in crisis intervention.
Choice B rationale:
Identifying social support is important but not the primary action in this situation.
Choice C rationale:
Instructing the client about coping skills is important, but immediate safety takes precedence.
Choice D rationale:
Exploring the client's perception of the event is valuable, but assessing for suicidality is more urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Magical thinking is a positive symptom of schizophrenia, involving unrealistic beliefs or perceptions.
Choice B rationale:
A flat affect is a negative symptom of schizophrenia characterized by reduced emotional expression. Negative symptoms involve a decrease or loss of normal functioning, and a flat affect is one of the most common negative symptoms seen in schizophrenia.
Choice C rationale:
Ideas of reference are also a positive symptom, involving the belief that neutral or unrelated events have special significance related to oneself.
Choice D rationale:
Clang association is another positive symptom, involving the association of words based on similar sounds rather than meaningful connections
Correct Answer is B
Explanation
Choice A rationale:
Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.
Choice B rationale:
Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.
Choice C rationale:
Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.
Choice D rationale:
Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.
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