A nurse is speaking with a client who is experiencing a situational crisis following the sudden death of his partner. Which of the following questions should the nurse ask the client first?
"Who do you talk to when you feel overwhelmed?"
"Are you thinking about harming yourself?"
"Can we talk about how your partner's death has affected you?"
"What do you usually do to calm your thoughts?"
The Correct Answer is B
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Monitoring the client for a period of time after meals helps prevent behaviors such as purging or excessive exercise, which individuals with anorexia nervosa might engage in to compensate for food intake.
Choice B rationale:
Encouraging a specific weight gain is not the initial priority. Weight restoration should be approached carefully and gradually to avoid refeeding syndrome.
Choice C rationale:
Allowing the client to exercise for less than 1 hr per day is a potential intervention, but the priority is to observe the client after meals to prevent harmful behaviors.
Choice D rationale:
Weighing the client in the morning every other day is an important monitoring step, but it is not the initial intervention during admission.
Correct Answer is B
Explanation
Choice A rationale:
Assigning an Apgar score is important, but drying the newborn and promoting warmth are immediate priorities.
Choice B rationale:
Drying the newborn and providing warmth help prevent heat loss and maintain the newborn's body temperature, which is essential for their well-being.
Choice C rationale:
Weighing the newborn is important, but maintaining their body temperature takes precedence immediately after birth.
Choice D rationale:
Placing an identification bracelet on the newborn is important for proper identification, but ensuring the newborn's immediate well-being and comfort is the priority.
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