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
Explanation
The correct answer is choice A: "I anticipate that my child will feel some self-blame."
Choice A rationale: Recognizing that the adolescent may experience self-blame demonstrates understanding and empathy from the guardian. This statement suggests that the guardian is aware of potential emotional challenges the adolescent might face and can provide appropriate support.
Choice B rationale: While monitoring relationships may come from a place of concern, overly controlling behavior could potentially harm the adolescent's social development and trust in their support system.
Choice C rationale: Encouraging the adolescent to focus solely on the future might dismiss their current emotional state and the importance of processing their feelings. A positive support system should provide space for the adolescent to work through their emotions.
Choice D rationale: Encouraging the adolescent to think about what they did that allowed the event to happen can promote feelings of guilt and self-blame. This approach is not supportive and could exacerbate the adolescent's trauma.
Correct Answer is B
Explanation
Choice A rationale:
Attending a cognitive behavioral therapy class does not require informed consent as it is a non-invasive form of treatment.
Choice B rationale:
Informed consent is necessary when taking an experimental medication to ensure the client understands the potential risks and benefits.
Choice C rationale:
Light therapy is a non-invasive treatment and does not typically require informed consent.
Choice D rationale:
Participating in a group exercise program is a non-invasive form of treatment and does not require informed consent.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.