Ch 12

10. Which of the common symptoms should the nurse anticipate during assessment of a client experiencing a crisis? 1. Feelings of depersonalization, loose associations, flat affect 2. Lack of regard to social norms, apathy, hallucinations 3. Mood swings, feeling of boundless energy, grandiose beliefs 4. Somatic complaints, difficulty performing life roles, poor concentration

Hide Answer 10. The answer is 4. A client who is experiencing a crisis has difficulty performing usual life roles because of acute distress. He also typically has somatic symptoms and poor concentration resulting from the physiologic stress response. All of the remaining symptoms commonly occur with the onset of mental illness, but they are not characteristic of a crisis response.

11. What is the best rationale for identifying client strengths when evaluating someone experiencing a crisis? 1. It allows the nurse to better determine the nursing diagnosis. 2. It helps the nurse understand the client's unique personality. 3. The nurse can better educate the client about his strengths. 4. Reinforcing the client's strengths will aid in coping.

Hide Answer 11. The answer is 4. An important principle of crisis intervention is the strengthening and support of healthy aspects of an individual's functioning. This is important because the client needs to resolve the crisis and identifying his individual strengths will enhance his ability to cope. Although the remaining responses are generally true and reflect good nursing practice, they are not the primary reason for assessing client strengths during a crisis.

12. The psychiatric nurse hears shouting in the day room and finds a client threatening to kick the television because the other clients in the room have refused to change the channel. The nurse intervenes by instructing other clients to leave the area. Which intervention is most appropriate to protect the nurse while using deescalating measures? 1. Position herself between the exit door and the client 2. Stand within an arm's length of the client 3. Stand next to the client with hands at her side 4. Sit in a chair next to the client

Hide Answer 12. The answer is 1. Standing between the client and the exit door will allow the nurse to quickly exit the area if the client attempts physical aggression. Standing within an arm's length of the client would not afford enough protection. Standing or sitting next to the client could be misinterpreted as a threat, and the client may lash out.

P.232 13. The medical-surgical nurse assesses a client who suffered a broken leg while attempting to leave her home, which was demolished by a fire. Which of the following questions are appropriate for the nurse to ask in this situation? Select all that apply. 1. "How did you feel about your parents while growing up?" 2. "What happened to you?" 3. "Who do you feel is supportive or helpful to you?" 4. "What have you done so far to try and resolve this crisis?" 5. "What kind of work do you do?" 6. "Do you have any hobbies that interest you?"

Hide Answer 13. The answer is 2, 3, 4. These questions will help the nurse understand the client's perspective of the crisis events, the available support systems, and the coping measures attempted thus far. The remaining options are irrelevant to the client's current predicament and will not assist the nurse in analyzing the crisis experience.

2. The nurse is intervening with a client who experienced a crisis following the sudden death of a loved one. Which of the following actions should the nurse take after establishing initial rapport? 1. Ask the client to describe his social support system. 2. Call the client's family to discuss the problem. 3. Encourage the client to describe in detail what happened. 4. Refer the client to a bereavement support group.

Hide Answer 2. The answer is 3. It is important for the nurse to assess the client's perception of the overwhelming problem and the events preceding the crisis situation because these are the factors that define the crisis. Determining the social support system is important; however, this assessment would follow the client's description of the problem (the first step in crisis intervention). Calling the family to discuss the problem or referring the client to a bereavement support group may or may not be appropriate, depending on the client's perception of the problem; but, again, these would occur later in the intervention.

3. The nurse assesses balancing factors to predict a client's response to a crisis and eventual outcome. Which of the following is the best example of a balancing factor? 1. Age 2. Physical health status 3. Situational supports available 4. Type of crisis event

Hide Answer 3. The answer is 3. Situational supports (family, friends, and others the client can rely on for help) are important balancing factors that will help predict a good outcome. Other balancing factors include the client's realistic (rather than distorted) perception of the crisis and the availability of effective coping mechanisms to alleviate anxiety. Although the client's age and physical health status may be influential in predicting outcome resolution, they are not considered balancing factors. Likewise, the type of crisis is not considered a balancing factor.

4. Which approach by the nurse is best when responding to a client in crisis? 1. Behavioral approach 2. Nondirective approach 3. Problem-solving approach 4. Supportive approach

Hide Answer 4. The answer is 3. Crisis intervention employs a systematic, problem-solving approach in attempting to help clients deal with crises. A behavioral approach or a nondirective approach would not be used. Although a supportive approach (supporting the client's strengths) is part of crisis intervention, the overall method guiding the nurse is the problem-solving approach.

5. Which of the following best describes the role of the nurse as a member of a crisis intervention team? 1. Assistive role 2. Collaborative role 3. Educational role 4. Managerial role

Hide Answer 5. The answer is 2. As an integral member of a health care team, the nurse must collaborate with other professionals to help clients resolve crises. The nurse may assist and teach clients during the process, but the chief role is one of a collaborative team member. The nurse may or may not assume a managerial role on the team.

6. Which outcome is most appropriate following nursing intervention for a client in crisis? 1. The client will analyze problems with lifestyle choices. 2. The client will improve weaknesses in personal development. 3. The client will learn new adaptive measures to decrease anxiety. 4. The client will return to a level of precrisis functioning.

Hide Answer 6. The answer is 4. Crisis intervention is designed to enable the individual, group, or community to return to a precrisis state of equilibrium as soon as possible by resolving immediate problems. Analyzing the client's lifestyle choices and improving weaknesses in personal development are goals more appropriate for a longer-term therapeutic intervention, in which the focus is on insight development. Although the client may learn new, adaptive measures as a result of crisis intervention, this is not the goal.

P.231 7. A client who has been raped tells the emergency department nurse that the rape was her fault because she walked down an alley on her way to school. Which response by the nurse would be best in this situation? 1. Accept the client's statement that this was risk-taking behavior. 2. Ask the client what other behaviors may have been risky. 3. Emphasize that the rapist, not the client, is responsible. 4. Suggest that the client discuss this issue later.

Hide Answer 7. The answer is 3. The client's feeling of self-blame is a common response to a rape-trauma crisis. However, this is not a realistic perception of the event, and the nurse should point out reality (telling the victim that the rapist is responsible). The responses in options 1 and 2 would only serve to reinforce the client's misperception that her own behavior caused the rape and, therefore, are incorrect. The response in option 4 is incorrect because it avoids addressing the client's distress and is unsupportive to the situation.

8. A client angrily shouts to the clinic nurse, "You'd better get me in to see the doctor now, or I'll see that you regret it." Which of the following is the best initial response by the nurse to deescalate this situation? 1. Call for assistance from security. 2. Explain to the client the reason why the doctor is busy. 3. Firmly tell the client not to shout, but to be patient. 4. Respond empathically to the client's underlying frustration.

Hide Answer 8. The answer is 4. In this situation, the nurse can best respond to the client's anger by using empathy to address his underlying feelings (frustration). This approach will help to deescalate anger. Because the client's anger has not escalated to physical, acting-out behavior, calling security would be premature. Defending the doctor is inappropriate in this situation. Also, this might further escalate the client's anger. It is important to respond to the client's underlying feelings. If the nurse firmly tells the client not to shout and to be patient, the client is likely to see this as nonsupportive and authoritarian, which would only escalate his anger.

9. A homeless client with a history of mental illness tells the clinic nurse that someone has taken all of the blood pressure pills she received at her last visit to the clinic. The nurse notes that the client is dirty and unkempt and appears to have lost weight since her last visit. Upon questioning, the nurse learns that the client has not been eating regularly because of her fear that the person taking the pills works at the local soup kitchen. Which nursing intervention is the priority in this situation? 1. Call the local mental health center and make a referral. 2. Make immediate provisions for the client to eat. 3. Provide the client with a new supply of medication. 4. Suggest that the client wash up in the clinic bathroom.

Hide Answer 9. The answer is 2. Following Maslow's Hierarchy of Needs to determine crisis intervention priorities, the nurse must make immediate provisions for the client to eat because this basic need is currently unmet. All of the remaining interventions would be appropriate during crisis intervention; however, providing nutrition is the first priority.

12 Crisis Intervention 1. The school nurse receives a referral from a teacher about a sudden behavior change in a 13-year-old girl who has become increasingly withdrawn and uninterested in her schoolwork. Upon interviewing the girl and her teacher, the nurse notes that the girl's behavioral changes correspond with a rapid onset of puberty. Which type of crisis is the girl experiencing? 1. Adventitious crisis 2. Developmental crisis 3. Situational crisis 4. Natural crisis

Hide Answer The answer is 2. A developmental crisis is one that occurs in response to a particular transition from one stage of maturation to another in the life cycle. Puberty marks the transition from childhood to adolescence. An adventitious crisis occurs in response to severe trauma or disaster. Asituational crisis occurs in response to sudden, unexpected events in an individual's life. Puberty is neither sudden nor unexpected; it is a normal transition. A natural crisis is not a clinical type of crisis.