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 D
Explanation
Choice A rationale:
Alcohol can interfere with sleep patterns and should not be used as a sleep aid.
Choice B rationale:
Napping can make it harder to fall asleep at night.
Choice C rationale:
Eating just before bedtime can cause discomfort and disrupt sleep.
Choice D rationale:
Limiting caffeine intake can help improve sleep, as caffeine is a stimulant that can interfere with the ability to fall asleep.
Correct Answer is B
Explanation
Choice A rationale:
Reaction formation is a defense mechanism where a person behaves in a way opposite to their true feelings.
Choice B rationale:
Somatization is the process of experiencing mental or emotional distress as physical symptoms.
Choice C rationale:
Intellectualization is a defense mechanism where a person uses reasoning to block out emotional stress.
Choice D rationale:
Sublimation is a defense mechanism where a person transforms unacceptable impulses into socially acceptable behaviors.
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