A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.
Reinforce teaching on the client's use of coping skills
Encourage the client to use personal support systems.
Assist with a client referral for social services.
Identify if the client has thoughts of self-harm.
The Correct Answer is D
Choice A rationale:
Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.
Choice B rationale:
Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.
Choice C rationale:
Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.
Choice D rationale:
Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.
Choice B rationale:
Being currently married is generally considered a protective factor against suicide, not a risk factor.
Choice C rationale:
Access to lethal means, such as guns in the home, is a significant risk factor for suicide.
Choice D rationale:
A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.
Choice E rationale:
Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.
Correct Answer is A
Explanation
Choice A rationale:
Acknowledging an inability to control drinking is the first step in many recovery models, including the 12-step program of Alcoholics Anonymous. This step involves admitting that alcohol has taken over one’s life.
Choice B rationale:
Agreeing to a prescription for an alcohol use deterrent can be a part of the recovery process, but it is not typically the first step.
Choice C rationale:
Incorporating a form of spirituality into daily life can be a part of the recovery process for some individuals, but it is not typically the first step.
Choice D rationale:
Forming a close support network is crucial in the recovery process, but it comes after acknowledging the problem.
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