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 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.

A. Lower the window shade in the client's room. B. Obtain a PRN prescription for a vest restraint. C. Place the client in a room close to the nurses' station. D. Request a consult with recreational therapy.

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.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?.

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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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?.