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 C
Explanation
Choice A rationale:
Increased serum amylase is a common finding in acute pancreatitis, and its decrease would be a positive sign. However, lipase is a more specific marker for pancreatic injury.
Choice B rationale:
Increased C-reactive protein is a marker of inflammation and would not necessarily indicate improvement in pancreatitis.
Choice C rationale:
Decreased serum lipase indicates improvement in the pancreatic injury and is a positive sign.
Choice D rationale:
Decreased platelets would not specifically indicate improvement in acute pancreatitis.
Correct Answer is B
Explanation
Choice A rationale:
A 7-month-old infant with Down syndrome is less likely to use a spoon.
Choice B rationale:
Crawling short distances is a developmental milestone that can be expected at this age.
Choice C rationale:
Speaking five to eight words is not an appropriate milestone for a 7-month-old infant.
Choice D rationale:
Standing with assistance usually occurs around 9-12 months, which might be delayed in infants with Down syndrome.
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