Crisis Theory and Intervention

724. A nurse is assisting in planing care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?

Answer: "Asking that the client reports suicidal thoughts immediately Rationale: One to one suicide precautions are required for the client who attempted suicide

721. A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client?

Answer: "Drawing" Rationale: Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities have no right or wrong choices or decision minimize opportunities for the client to put down himself or herself.

720. The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to.

Answer: "Examine and treat the wound site" Rationale:The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from Lacerated wrist can lead to a life threatening situation. Other intervention may follow after the client has been treated medically Administer an anti anxiety agent Secure and record a detailed hx Encourage and assist the client to vent feeling

716. A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

Answer: "You must be feeling all alone at this point" Rationale: The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings

729. During a conversation with a depressed client on a psychiatric unit, The client says to the nurse. " The nurse should make which therapeutic response to the client?

Answer: "You sound very upset. Are you thinking of hurting yourself?" Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self harm exist

727. A nurse is assisting in developing a plan of care for the client in crisis state. When developing the plan, the nurse will consider which of the following.

Answer: A client response to a crisis is individualized and what constitutes as a crisis for one person may not constitute a crisis for another person. Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned what constitute a crisis for one person may not constitute a crisis for another person

726. A nurse is gathering data from a client in crisis. When determining the clients perception of the precipitating event that led to crisis, the most appropriate question to ask is:

Answer: What leads you to seek help now? Rationale: A nurse initial task when gathering data from a client in crisis is to access the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found

717.A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which interventions in the plan of care?

Answer: "Assigning the client to a room at the end of the hall to prevent disturbing the other client" Rationale: The client should be placed in a room near the nurses station and not the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the clients room. The door to the clients room should be kept open, and the nurse should never turn away from the client.

723. An older client is a victim of elder abuse, and the clients family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills?

Answer: "I feel better able to care for my father now that I know where to obtain assistance" Rationale: Elder abuse sometimes occurs with family member who are being expected to care for their aging parents. This can cause family member to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance in caring for aging family members can bring much needed relief.

730. A nurse is preparing to care for a dying client, and several family members are at the clients bedside. Which therapeutic techniques should the nurse use when communicating with the family?

Answer: Encourage Expression of feelings, concerns, and fears, Extended touch and hold the clients or family members hand if appropriate and be honest and truthful and let the client and family know that you will not abandon them.

728. A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client?

Answer: What is causing you to become agitated? Rationale: The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and will assist the nurse in planning appropriate intervention for the client.

719. A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurses most important aspect of care is to maintain client safety and plans to:

Answer: "Request that a peer remain with the client at all times" Rationale: Hanging is a serious suicidal attempt. The plan of care must reflect action that will promote clients safety. Constant observation status (One on One) with a staff member who is never less than an arms length away is the safest intervention

718. Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

Answer: The clients gives away prized CD and a cherished autographed picture of the performer Rationale: A depressed suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered

722. A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:

Answer: "Offer the client choices and consequences to the failure to comply with expectation of maintaining activities of daily living" Rationale: The client with depression may not have the energy or interest to complete activities of daily living. Often,severely depressed clients are unable to perform even the simplest activities of daily living

725. A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of situational crisis. The nurse would determine that this type of crisis could be caused by:

Answer: The death of a loved one Rationale: A situation crisis is associated with a life event. External situation that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce and severe illness