Nclex Review: Crisis
The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which of the following factors? 1. Relinquishment of dysfunctional coping. 2. Reestablishment of lost support systems. 3. Acquisition of new coping skills. 4. Gain of crisis prevention knowledge.
3. Learning new coping skills is the major factor necessary for higher functioning. Better coping is likely to lead to regaining support systems, giving up dysfunctional coping, and awareness of how to prevent future crises.
A client who comes to the crisis center in a very distressed state tells the nurse, "I just can't get over being fired last week. I've asked for help. I've talked to friends. I've tried everything to get through this, but nothing is working. Help me!" Which of the following should the nurse use as the initial crisis intervention strategy? 1. Referral for counseling. 2. Support system assessment. 3. Emotion management. 4. Unemployment assistance.
3. Letting the client express his feelings (emotion management) is essential before trying to problem solve about the situation or deciding what kind of referral is appropriate. A referral for counseling, assessment of the client's support system, and unemployment assistance may be appropriate after the client's anxiety is reduced.
A nurse manager of the Crisis Access Center of a psychiatric facility in New York City notices a sudden increase in the number of incoming calls one afternoon. After quickly surveying the call sheets, the nurse finds that most callers are very anxious after Air Force One flew very low over the city so that pictures could be taken of the President's plane near famous sites. Which of the following strategies would be most appropriate in this situation? Select all that apply. 1. Instruct the crisis workers to additionally screen callers about where they were on 9/ 11/ 01 and their memories of that event. 2. Give the crisis workers a list of symptoms of PTSD and techniques for dealing with these symptoms. 3. Ask for an emergency meeting with the managers of the inpatient and outpatient services to formulate a contingency plan for increased services if needed. 4. Ask the major media outlets in the city to make a scripted public service announcement about the possible recurrence of symptoms experienced after the events of 9/ 11/ 01. 5. Prepare for a scripted interview with the local media about PTSD symptoms and techniques for dealing with these symptoms. 6. Ask the Director of Psychiatric Services to call the U.S. Government to ask that the President issue an apology for the flyover by Air Force One.
1, 2, 3, 4, 5. All of the options are correct and in an appropriate sequence of actions except for Option 6. The flyover of Air Force One over New York City is likely to trigger vivid memories and emotions in those living near the city related to the tragedy of the Twin Towers on 9/ 11/ 01. The severity of the flashbacks will vary in degree, just as they did after the original event. It is not appropriate to call the government to ask for an apology.
A grandson who calls the crisis center expressing concern about his grandmother who lost her husband a month ago states, "She has been in bed for a week and is not eating or showering. She told me that she did not want to kill herself, but it's not like her to do nothing for herself. She won't even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which of the following reasons? 1. The behaviors may reflect passive suicidal thoughts. 2. The behaviors reflect altered role performance. 3. Seeing the grandson and grandmother together will be helpful. 4. Refusing to talk to the grandson alone indicates a major problem.
1. Passive suicidal thoughts, such as a wish to die or giving up on self-care, can be as much of a risk as active suicidal ideation (the idea of killing one's self directly), especially for older clients because they commonly lack the means, energy, and motivation for an active suicide attempt. Seeing the grandson and grandmother together may help later. Not talking to the grandson and experiencing altered role performance may be real issues, but these are not as critical as the risk of indirect (passive) suicide.
On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend sniffs glue. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, the nurse should consider which of the following? 1. The boys probably fear punishment. 2. Sniffing glue is illegal. 3. The boys' observations could be wrong. 4. Glue-sniffing is a minor form of substance abuse.
1. Telephoning the crisis shelter indicates that the boys are alarmed but are reluctant to talk with their parents. The boys may fear that their parents will assume that they have been sniffing glue and punish them. The nurse should focus on helping the boys talk with their parents. Although sniffing glue is dangerous and potentially lethal, it is not illegal. To prove that the observations are incorrect requires an intervention beginning with the boys' parents. Sniffing glue is included in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised, as inhalant abuse. It is not a minor form of substance abuse.
While teaching a group of volunteers for a crisis hotline, a volunteer asks, "What if I'm not sure why someone is calling?" Which of the following statements by the nurse is most helpful? 1. "Ask the caller to tell you why he or she is calling you today." 2. "Tell the caller to make an appointment at the walk-in crisis clinic." 3. "Instruct the caller to go to the nearest emergency room." 4. "Tell the caller to let you speak to anyone else in the house."
1. The crisis worker needs to use active focusing techniques to determine the crisis-precipitating event or the immediate problem. Asking the caller, "Why are you calling today?" or "What is the immediate problem?" will assist the caller to focus on the specific need or event. Telling the client to make an appointment is inappropriate because the problem might be life-threatening. Telling the caller to go to the nearest emergency room is precipitous and may be unnecessary. Asking to speak to someone else in the home may be futile because the caller might be alone. This action also ignores the caller and his or her feelings.
The nurse incorporates the underlying premise of crisis intervention, about providing "the right kind of help at the right time," to achieve which of the following goals initially? 1. Regaining emotional security and equilibrium. 2. Resolution of underlying emotional problems. 3. Development of insight and personal growth. 4. Formulation of more effective support systems.
1. The initial goal in crisis intervention is helping the client regain emotional security and equilibrium. Resolution of the underlying emotional problems, development of insight and personal growth, and formulation of more effective support systems are goals to address as the crisis subsides.
During the interview at a crisis center, a newly widowed client reveals the wish "to join my husband in Heaven." After the nurse asks the client to sign a no harm contract, which of the following statements is appropriate to say next? 1. "Tell me what feelings you have been experiencing." 2. "Has your husband's estate been settled yet?" 3. "What was the cause of your husband's death?" 4. "Do you have children who are willing to help you?"
1. The nurse needs to focus on the client and address her feelings. Talking about her feelings helps to decrease the risk of self-harm. Doing so takes precedence over questions about the husband's estate, the cause of death, and her children's support.
A family, including an 8-year-old boy and a 13-year-old girl, have been long-time members of a cult split off from a conservative religious group. The girl ran away from the group's compound to her aunt's house. The aunt brought the girl to the emergency department after finding multiple knife cuts in various stages of healing on the girl's body. She is admitted to the unit because of many trauma-related symptoms. The nurse should take which of the following actions? Select all that apply. 1. Ask her to describe her experiences in a discussion group with other teens. 2. Teach her emotion management skills to help her deal with her "normal reactions to an abnormal situation." 3. Assess her for other possible injuries, pregnancy, and sexually transmitted diseases. 4. Teach her ways to control self-destructive behaviors such as suicide attempts, self-mutilation, and rage outbursts. 5. Obtain a sample for a urine drug screen and routine urinalysis. 6. Help her process her emotions and memories as she is willing to share these.
2, 3, 4, 5, 6. Controlling self-destructive behaviors is a priority, but developing emotion management skills and processing emotions and memories are also important. Assessing for injuries, pregnancy, STD's and drugs in her system is important due to the fact that most cults foster sex and pregnancy in young teens and often use drugs to achieve compliance from the girls. It is not appropriate to ask the client to share her experiences in a group of teens. It could be more damaging to the client unless the other teens are also trauma/ torture survivors.
A potentially pregnant 16-year-old client says that she has been "hooking up" with a boy she considers to be her boyfriend. Which of the following responses should the nurse make first? 1. "You mean you have had sexual intercourse?" 2. "Describe what you mean by hooking up." 3. "I think we need to talk about what's involved in sexual intercourse." 4. "All you have been doing with your boyfriend is hooking up?"
2. Because of the client's potential pregnancy, the nurse needs to determine exactly what the client means by the term "hooking up" by asking the client to describe what she has been doing in sexual encounters with her boyfriend. Asking the client if she means sexual intercourse or telling the client that they need to talk about sexual intercourse makes an assumption that may or may not be appropriate. The nurse needs to determine exactly what the client means by the terms used. Repeating the client's statement does not elicit the necessary information to interpret the client's statement. Additionally, this type of response assumes an understanding of what the client has said.
A major role in crisis intervention is getting a client's significant others involved in helping with the immediate crisis as soon as possible. The nurse should determine that the support persons are prepared to help when they verbalize which of the following? 1. The name and phone number of the client's physician. 2. Emergency resources and when to use them. 3. The coping strategies they are using. 4. Long-term solutions they plan to tell the client to use.
2. During a crisis, support persons demonstrate preparedness to help the client by verbalizing the emergency resources available and knowing when to use them. Follow-up medical care may be helpful as the crisis subsides. The coping strategies used by the support persons may or may not be relevant to the client's needs and situation. Long-term solutions and advice may or may not be appropriate. The focus needs to be on the client's immediate needs and situation.
A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for which of the following lengths of time? 1. 1 to 2 weeks. 2. 4 to 6 weeks. 3. 12 to 14 weeks. 4. 24 to 26 weeks.
2. Generally, 4 to 6 weeks is viewed as the length of time a client can tolerate the severe level of disturbance of a true crisis. In the first week or two, the client usually is still trying to use normal coping skills and support systems. After 6 weeks of continuous crisis, a client is probably becoming so physically and emotionally drained that he has sought or has been brought by others for medical or psychiatric care.
A 16-year-old client who is being seen by the crisis nurse after making several superficial cuts on her wrist complains that all her friends are siding with her ex-boyfriend and won't talk to her anymore. She says she knows that the relationship is over, but "If I can't have him, no one else will." Which of the following nursing diagnoses is most important? 1. Situational low self-esteem related to rejection by friends as evidenced by friends not talking to her. 2. Risk for other-directed violence related to break-up of the relationship as evidenced by the statement, "If I can't have him, no one else will." 3. Risk for suicide related to loss of the relationship as evidenced by client's acting-out behaviors. 4. Risk prone health behavior related to rejection by the boyfriend as evidenced by self-mutilation.
2. The threat toward the ex-boyfriend is the most immediate concern now, as the client turns her anger toward him instead of herself. Although Situational low self-esteem, Risk for suicide, and Risk prone health behavior are accurate, these nursing diagnoses are less of a concern at this time.
38. An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and saying that she thinks she is pregnant but does not know what to do. Which of the following nursing interventions is most appropriate at this time? 1. Ask the client about the type of things that she had thought of doing. 2. Give the client some ideas about what to expect to happen next. 3. Recommend a pregnancy test after acknowledging the client's distress. 4. Question the client about her feelings and possible parental reactions.
3. Before any interventions can occur, knowing whether the client is pregnant is crucial in formulating a plan of care. Asking the client about what things she had thought about doing, giving the client some ideas about what to expect next, and questioning the client about her feelings and possible parental reactions would be appropriate after it is determined that the client is pregnant.
A nurse in an Employee Assistance Program (EAP) is seeing a woman who wants to report her boss to the police for sexual harassment. She states he says that she will never get a promotion unless she "works and plays at his house on weekends." After getting more details on the boss' statements and behaviors, the nurse should do which of the following? 1. Encourage the client to file a police report as soon as possible. 2. Tell the client to return to EAP if she is denied a promotion. 3. Show the client the company's Workplace Violence Policy and agree to help her follow the process. 4. Go with the client to confront her boss about his behaviors and possible consequences.
3. Employers are required to have a Workplace Violence Policy that outlines procedures related to this issue. Filing a police report may or may not be appropriate after the procedures of the policy are completed. Having the client only come back to EAP if a promotion is denied is an inappropriate suggestion. Confronting the boss with the client is only needed if other steps of the procedure are not effective.
After teaching a group of students who are volunteering for a local crisis hotline, the nurse judges that further education about crisis and intervention is needed when a student states which of the following? 1. "Callers to a crisis line use this service when they're overwhelmed and exhausted." 2. "People use crisis hotlines when they're in the most pain and nothing is working for them." 3. "Most people in crisis will be calling the line once every day for at least a year." 4. "One benefit is that a person will know how to handle stressful situations better in the future."
3. The concern that someone may call the crisis hotline every day for a year indicates that further understanding about crisis and crisis intervention is needed. A crisis situation is time-limited, typically resolving in 4 to 6 weeks if handled effectively. If a person calls the line daily for a year, that person has not been properly dealt with or is probably in a highly disorganized state requiring an alternative intervention. The nurse needs to further review and clarify the material presented. Callers are typically in pain, overwhelmed, and exhausted when they call. A crisis can help an individual cope better in the future if he learns to handle the situation.
A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the receipt of a divorce notice. Which of the following, if verbalized by the client, indicates to the nurse that the client is ready for discharge? 1. A readiness for discharge. 2. Names and phone numbers of two divorce lawyers. 3. A list of support persons and community resources. 4. Emotional stability.
3. The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it is important for the client to be able to verbalize information about appropriate support persons and community resources and to have this information readily available. Although the client may state that she is ready to be discharged, this is not the most reliable indicator. A divorce lawyer may not be appropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.
A 40-year-old client who is quite anxious says that she would "rather die than be pregnant." Which of the following responses by the nurse is most helpful? 1. "Try not to worry until after the pregnancy test." 2. "You know, pregnancy is a normal event." 3. "You're only 40 years old and not too old to have a baby." 4. "I see you're upset. Take some deep breaths to relax a little."
4. Because people in an emotional crisis find it difficult to focus their thinking, the goal is to return the client to noncrisis functioning. Pointing out and decreasing the client's level of anxiety is the first step in attaining this goal. Telling an obviously distressed person not to worry is ineffective because it ignores the client's distress and concerns. Although pregnancy is a normal event, and 40 years of age may not be too old for a pregnancy, these responses also ignore the client's distress and feelings.
Three months after the death of her husband in an automobile accident, a client is admitted to the hospital after attempting to overdose on her antidepressant. She states, "I can't live without him. It's no use. I just want to die." Which of the following nursing diagnoses is the priority in the client's plan of care? 1. Complicated grieving related to husband's death as evidenced by a suicide attempt. 2. Powerlessness related to husband's death as evidenced by statement of "It's no use." 3. Hopelessness related to husband's death as evidenced by the client's statement of inability to live without the husband. 4. Risk for self-directed violence related to husband's death as evidenced by the client's wish to die.
4. Risk for self-directed violence is the priority nursing diagnosis for a client who has attempted or verbalizes the intent to harm herself. Although the client is depressed, feeling hopeless and powerless, and is grieving, these are not the priority concern at this time.
A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which of the following statements by the father should alert the nurse to the need for a psychiatric consultation? 1. "My son will be fine, but I may be charged with reckless driving." 2. "His mother is going to kill me when she finds out about this." 3. "I just didn't see him run behind the car." 4. "If he dies, there will be nothing for me to do but join him."
4. The statement about joining the son if he dies indicates potential for self-harm and subsequent suicide, always a risk during crisis. Although the father may be charged with reckless driving, this is not an indication for a psychiatric consultation. Although the son's mother may be extremely upset and angry about the event, this statement is more likely an overstatement, not a real risk. The statement about not seeing the son run behind the car illustrates the father's attempts at trying to process the situation.
