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 B
Explanation
Choice A rationale:
Hypomagnesemia is not a common finding in clients with bulimia nervosa.
Choice B rationale:
Hypokalemia is a common finding due to purging behaviors, such as self-induced vomiting or misuse of laxatives, which can lead to loss of potassium.
Choice C rationale:
Muscle wasting is more commonly associated with anorexia nervosa, not bulimia nervosa.
Choice D rationale:
Lanugo, or fine body hair, is also more commonly associated with anorexia nervosa, not bulimia nervosa.
Correct Answer is C
Explanation
Choice A rationale:
Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.
Choice B rationale:
Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.
Choice C rationale:
Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.
Choice D rationale:
While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.
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.
