Saunders Chapter 65: Crisis Theory and Interventions
7. A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first? 1. Encourage the client to talk about the experience. 2. Administer an anxiolytic medication as prescribed at once. 3. Examine the neck area and assess the airway. 4. Obtain a detailed history of events leading to the attempt.
ANS: 3 Rationale: The nurse should first assess the airway and prepare to treat injuries to the neck area. Failure to do so could be life threatening. Other interventions may follow after the client has received medical intervention for physical injuries.
2. A nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that which of the following is the immediate priority of care? 1. Provide the other clients on the unit with a sense of comfort and safety by isolating the client. 2. Assist in caring for the client in a controlled environment, such as a quiet room. 3. Provide safety for both the client and other clients on the unit. 4. Offer the client a less stimulating area in which to calm down and gain control.
ANS: 3 Rationale: Safety for both the client and other clients is the priority. Option 3 is the only option that addresses the client's and other clients' safety needs. Options 2 and 4 address only the client's needs. Option 1 addresses only the needs of the other clients in the unit.
6. A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, would take which immediate action? 1. Have the client put on a hospital gown and remove the client's clothing from the room. 2. Request that a friend of the client remain with the client at all times. 3. Stay with the client at all times. 4. Suggest placing the client in a seclusion room where all potentially dangerous articles are removed.
ANS: 3 Rationale: The plan of care for a client with a suicide attempt must reflect action that will promote the client's safety. Constant observation status (one on one) is the immediate intervention. Options 1 and 4 do not provide constant observation of the client. Option 2 places an unfair burden on the friend of the client, which is inappropriate.
4. A nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response by the nurse would be appropriate at this time? 1. "You sound very unhappy. Are you thinking of harming yourself?" 2. "Those feelings will go away once your medication really takes effect." 3. "I know what you mean; everyone gets that way when they are depressed." 4. "Have you talked to anyone specifically about what is bothering you?"
ANS: 1 Rationale: Clients who are depressed may be at higher risk for suicide. When clients make statements such as the one in the question, it is critical for the nurse specifically to assess suicidal ideation and plan. The best method is to ask the client directly about whether a specific plan has been formed. Options 2, 3, and 4 do not directly focus on the client's statement.
3. A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action? 1. Sit beside the client in silence with occasional open-ended questions. 2. Ask direct questions to encourage talking. 3. Leave the client alone but check on her every 30 minutes. 4. Take the client into the dayroom with other clients for added supervision.
ANS: 1 Rationale: Clients who are withdrawn may also be immobile and mute (catatonic stupor). These clients require consistent, repeated approaches to establish interpersonal contact. The nurse facilitates communication with the client by sitting in silence and asking open-ended questions, with pauses to provide opportunities for the client to respond. Options 2, 3, and 4 are not appropriate nursing interventions.
9. A nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of a nursing diagnosis of Dysfunctional grieving related to the loss of a spouse. The client progresses well and is approaching discharge. Which of the following is an appropriate outcome for this nursing diagnosis? 1. The client verbalizes stages of grief and plans to attend a community grief group. 2. The client verbalizes connections between significant losses and low self-esteem. 3. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide. 4. The client reports three additional coping strategies.
ANS: 1 Rationale: The question identifies a nursing diagnosis of Dysfunctional grieving. The only option that deals with grief is option 1. Options 2, 3, and 4 are unrelated to this nursing diagnosis.
8. A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior? 1. Notify the staff of these observations at the team meeting due to begin in 3 hours' time. 2. Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide. 3. Document that the client is adapting to the unit and is feeling safe. 4. Continue to monitor the client's behavior from a distance.
ANS: 2 Rationale: A sudden improvement in a depressed client's mood may indicate that the client has decided to commit suicide. The most direct way to validate the nurse's impression is to ask the client directly about suicidal ideation or plans. The other options are not appropriate initially.
5. A nurse is caring for an elderly client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse would make which appropriate response? 1. "I'm sure you have someone if you think hard enough." 2. "It sounds as though you are feeling all alone right now." 3. "I don't believe that, and I really don't think you do either." 4. "That doesn't sound like the real you talking!"
ANS: 2 Rationale: The client is experiencing loss due to the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is the one that attempts to translate words into feelings. The statements in options 1 and 3 deny the client's feelings. The statement in option 4 puts distance between the nurse and client because it does not address the client's concerns.
A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which of the following would be the therapeutic response by the nurse? 1. "You seem angry, but you must understand that your neighbors are frightened because of your serious crimes against children." 2. "Try to realize how fortunate you are that our society doesn't let the group escalate to more punitive measures after your crimes against children." 3. "Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?" 4. "It's sad for you, but when children are hurt as you hurt them, people want you identified and isolated."
ANS: 3 Rationale: Focusing and verbalizing the implied are therapeutic communication techniques because they assist the client to clarify thinking and to relook at what the client is really saying. The correct option is the only one that reflects the use of this therapeutic communication technique. The remaining options do not focus on the client's statement and are blocks to communication.
10. A nurse working in an urgent care center is interviewing a woman with vague somatic complaints. Once the nurse is alone with the client, the client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client? 1. "It is very, very hard to get over these types of feelings after being raped." 2. "It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred." 3. "What do you think you should do to reduce the likelihood that you will be raped again?" 4. "Tell me more about what happened, which causes you to feel like the rape just occurred."
ANS: 4 Rationale: The correct option explores the client's thoughts and feelings directly and fully. At the same time, it conveys a nonhurried, nonjudgmental, and supportive attitude that is therapeutic. The client needs reassurance that these feelings are normal and may be expressed in this safe care environment. Option 1 places the client's feelings on hold, and option 2 blocks further communication. Option 3 is likely to increase the client's fear.
