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
Choice A rationale:
Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. It’s important to avoid showing too much emotion, which could be misinterpreted by the client.
Choice B rationale:
Being vague when answering the client’s questions about instructions could increase the client’s paranoia. Clear and direct communication is essential.
Choice C rationale:
Asking the client why he is suspicious of others could lead to defensive behavior. It’s better to focus on building trust and understanding.
Choice D rationale:
Using an overly friendly approach could be perceived as insincere or manipulative by a client with paranoid personality disorder. A neutral demeanor is more effective.
Correct Answer is D
Explanation
Choice A rationale:
Checking blood pressure once a week is a good practice, especially for clients on medications that can affect blood pressure.
Choice B rationale:
Chewing sugar-free gum several times daily is not harmful and can help with dry mouth, a common side effect of haloperidol.
Choice C rationale:
Avoiding alcohol while taking haloperidol is recommended as alcohol can increase the side effects of the medication.
Choice D rationale:
Spending several hours a day outside gardening when it’s sunny can lead to a condition called photosensitivity, a side effect of haloperidol. The client should be advised to wear protective clothing and sunscreen when outside.
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