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 C

Explanation

Choice A rationale:

While liver enzymes are important to monitor for many medications, they are not typically affected by lithium.

Choice B rationale:

Uric acid levels are not typically affected by lithium.

Choice C rationale:

Lithium can affect the sodium levels in the body, making it important to monitor these levels while taking this medication.

Choice D rationale:

Erythrocyte sedimentation rate is not typically affected by lithium.

A. Document the client's behavior in the medical record every 1 hr B. Provide range-of-motion exercises to all extremities every 2 hr. C. Request the provider renew the prescription in 24 hr. D. Keep staff interactions with the client to a minimum.

Correct Answer is B

Explanation

Choice A rationale:

Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.

Choice B rationale:

Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.

Choice C rationale:

The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.

Choice D rationale:

Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.

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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?.

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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?.