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 A

Explanation

Choice A rationale:

Re-engaging the child in an appropriate activity is a good example of the redirection technique.

Choice B rationale:

Moving closer to the child when they are agitated could escalate the situation rather than calm it.

Choice C rationale:

Using role-playing to enhance new behavioral skills is a good strategy, but it is not an example of the redirection technique.

Choice D rationale:

Ignoring attention-seeking behaviors could lead to an escalation of those behaviors as the child seeks attention.

A. "Having a newborn must be stressful. Do you have other children?". B. "Tell me about your baby. Where is she now?". C. "Do you have a friend who could help you?". D. "Have you discussed this with your partner?".

Correct Answer is B

Explanation

Choice A rationale:

While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.

Choice B rationale:

This response is the priority as it assesses the immediate safety of the baby.

Choice C rationale:

While support is important, the immediate safety of the baby is the priority.

Choice D rationale:

While communication with the partner is important, the immediate safety of the baby is the priority.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique? .

Correct Answer is A

Explanation

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.

Correct Answer is B

Explanation

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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?.