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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Using restraints can lead to injury and is generally a last resort.

Choice B rationale:

Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.

Choice C rationale:

Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.

Choice D rationale:

While medication can be helpful, non-pharmacological interventions should be tried first.

A. Restrict interactions with other clients B. Document the client's behavior every 2 hr. C. Implement 24-hr one-to-one nursing observation. D. Administer prescribed medication via the IM route.

Correct Answer is C

Explanation

Choice A rationale:

Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.

Choice B rationale:

Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.

Choice C rationale:

Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.

Choice D rationale:

Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.

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A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.