The nurse understands that whether or not a client experiences crisis as a result of a stressful situation depends on the: (SELECT ALL THAT APPLY)

time of day.

client's perception of the event.

availability of adequate coping mechanisms.

availability of supports.

Answer and Explanation

Correct Answer : B,C,D

a. time of day. The time of day is not a significant factor in determining whether a situation will be perceived as a crisis.
b. client's perception of the event. This is correct because an individual's perception of an event greatly influences whether it is experienced as a crisis.
c. availability of adequate coping mechanisms. This is correct because having effective coping mechanisms can mitigate the impact of a stressful situation and prevent it from becoming a crisis.
d. availability of supports. This is correct because having a supportive network can help individuals manage stress and reduce the likelihood of a crisis.
e. location of a treatment centre. While access to treatment is important, the immediate experience of a crisis is more influenced by perception, coping mechanisms, and support systems than the location of a treatment centre.

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Correct Answer is B

Explanation

a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.

A. "Focus on the feelings generated by the hallucinations and present reality." B. Ignore what they are saying, while attempting to discover the underlying cause." C. "Present objective evidence that the voices are not real." D. Tell them to stop discussing the voices.

Correct Answer is A

Explanation

a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.

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The nurse understands that whether or not a client experiences crisis as a result of a stressful situation depends on the: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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