Ch 67 Crisis Silvestri 452 E2 Brown

827. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."

827. Answer: 3 Rationale: The most appropriate statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate. Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate option 1 because of the demand that it places on the client. Eliminate options 2 and 4 because they indicate threats to the client.

838. The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation

838. Answer: 1 Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary. Test-Taking Strategy: Note the strategic word, priority. Focus on the subject of the question, which relates to providing the client with a safe environment. The correct option provides a specific plan for safety.

828. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

828. Answer: 2 Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse). Test-Taking Strategy: Note the subject, situational crisis. Recall that this type of crisis arises from an external source, is often unanticipated, and is associated with a life event that upsets an individual's or group's psychological equilibrium. This will direct you to the correct option.

829. The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

829. Answer: 3 Rationale: The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills. Test-Taking Strategy: Note the strategic words, most appropriate. Also note the subject, assessment techniques for the client in crisis, and note the words precipitating event and led to the crisis. Eliminate options 1 and 2, because these data would determine support systems. Eliminate option 4, because this question would be asked when determining coping skills.

830. The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

830. Answer: 4 Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client, because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness. Test-Taking Strategy: Eliminate option 3 because of the closed-ended word "all." Next, eliminate options 1 and 2, because a crisis does not indicate "illness."

831. The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? 1. Signs of depression 2. Reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

831. Answer: 2 Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate an expected reaction. Options 1, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Note the subject, client response to a crisis. Use knowledge regarding client responses to devastating events and focus on the symptoms noted in the question to direct you to the correct option.

832. A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

832. Answer: 4 Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings. Test-Taking Strategy: Note the strategic word, best. Recalling therapeutic communication techniques will assist in directing you to the correct option. Option 4 is the only option that deals directly with the client's feelings. In addition, clients at risk for suicide need to be assessed directly regarding the potential for self-harm.

833. The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client. 5. Allow the client to take control of the situation.

833. Answer: 2, 3, 4 Rationale: During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period. Test-Taking Strategy: Focus on the strategic word, most, and focus on the subject, the most helpful nursing interventions. Also note the words aggressive behaviors and escalating. Recalling that, during the escalation period, the client's behavior is moving toward loss of control and that the least restrictive measures should be used will direct you to the correct options.

834. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

834. Answer: 1 Rationale: A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of an adolescent. Test-Taking Strategy: Eliminate options 2, 3, and 4 because they are comparable or alike. The correct option is different and is an action that could indicate that the client may be "saying goodbye."

835. The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? 1. Administer an antianxiety agent. 2. Assess and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.

835. Answer: 2 Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been treated medically. Test-Taking Strategy: Note the strategic word, initial. Use Maslow's Hierarchy of Needs theory to prioritize. Physiological needs come first. The correct option addresses the physiological need.

836. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed

836. Answer: 3 Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm herself or himself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations. Test-Taking Strategy: Focus on the subject, suicide precautions. Options 1 and 4 support the client's notion that a cure has occurred. Option 2 allows the client to increase self-isolation and would present a threat to the client's safety. Knowing that safety is of the utmost importance will direct you to the correct option.

837. The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately

837. Answer: 1 Rationale: One-to-one suicide precautions are required for a client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm herself or himself. Test-Taking Strategy: Focus on the strategic word, priority, noting the words attempted suicide. The correct option is the only one that provides a safe environment.

839. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"

839. Answer: 3 Rationale: The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem solving totally on the client. Test-Taking Strategy: Note the strategic words, most appropriate. Also, focus on the subject, that the client feels that the rape just happened yesterday. Use therapeutic communication techniques. The correct option is the only one that addresses the client's feelings. Always address the client's feelings first.

840. A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times. 2. Removing the client's clothing and placing the client in a hospital gown. 3. Assigning to the client a staff member who will remain with the client at all times. 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed.

840. Answer: 3 Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used. Test-Taking Strategy: Note the strategic word, best. Focus on the subject, care of the client at risk for suicide. Eliminate option 4, because seclusion should not be the initial intervention. Eliminate option 1 next, because safeguarding a client is not the peer's responsibility. Eliminate option 2, because removing one's clothing would not maximize all possible safety strategies.

841. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times."

841. Answer: 2, 3, 5 Rationale: Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with post-traumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions. Test-Taking Strategy: Focus on the subject, post-traumatic stress disorder. There is no indication about a fear of spiders being part of the problem. There is no information in the question to support that the client has ritual behaviors. The client stating that they do not want anything to eat at the time is not relevant to this client's situation. Responses 2, 3, and 5 all indicate that the client is experiencing post-traumatic stress disorder from a recent home invasion and robbery event.