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 D
Explanation
Choice A rationale:
Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.
Choice B rationale:
Instructing the client to apologize to their family is judgmental and not therapeutic.
Choice C rationale:
Assuming the family's emotions and feelings is not appropriate and may not be accurate.
Choice D rationale:
Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.
Correct Answer is D
Explanation
- Rationale for Choice A: Pulmonary hygiene is important for preventing pneumonia, especially in bedridden clients. However, it is not specific to the care of a client with leukemia unless they have a respiratory complication which necessitates such an intervention.
- Rationale for Choice B: Airborne precautions are typically used for clients who have infections that can be transmitted through the air, such as tuberculosis. Leukemia does not require airborne precautions unless the client has a coexisting airborne infection.
- Rationale for Choice C: Regular turning of the client can help prevent pressure ulcers and is a good practice for any bedridden patient. However, the use of powder is controversial as it can cake and lead to skin breakdown, and is not specifically indicated for leukemia care.
- Rationale for Choice D: Assessing the client's urine for odor and cloudiness is an important part of care for clients with leukemia. They are at increased risk for urinary tract infections due to immunosuppression, and changes in urine can indicate an infection that needs prompt treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.