A nurse is caring for a who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
Identify the clients’ coping skills.
Determine the cause of the client's anxiety.
Ensuring that the client feels safe.
Protecting the client from injury
The Correct Answer is D
During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
In this scenario, the client has expressed a serious threat to harm someone, which triggers a healthcare provider's duty to warn law. The nurse appropriately informed the healthcare provider, who then informed their boss, to protect the potential victim from harm. This action is not a violation of privacy or confidentiality, as it is necessary for the safety and wellbeing of others.
Therefore, no disciplinary action is required for the nurse or the healthcare provider, as they acted in accordance with their professional and legal obligations to protect the safety of others.
Correct Answer is B
Explanation
The ethical principle of autonomy refers to an individual's right to make decisions about their own healthcare, treatment, and life choices. As a registered nurse, it is important to respect and promote the autonomy of patients. Option b best exemplifies the implementation of the ethical principle of autonomy because it involves exploring alternative solutions with the patient and allowing them to make their own choice among those alternatives. This approach respects the patient's right to make decisions about their own care, while also ensuring that they have the information they need to make an informed decision.
Option a suggests that the nurse is imposing their own decision on the patients, which violates the principle of autonomy.
Option c may involve staying with the patient to provide support and reassurance, but it does not necessarily involve promoting the patient's autonomy.
Option d involves intervening to prevent harm to the patient, which may be necessary at times but is not necessarily an example of promoting the patient's autonomy.
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