Nokea
A nurse assesses an adult experiencing a crisis. What question asked by the nurse will best determine situational support?
- A. Has anything upsetting occurred in the past few days?
- B. Who can be helpful to you during this time?
- C. How does this problem affect your life?
- D. What led you to seek help at this time?
Correct Answer: B
Rationale: This question directly assesses available situational support, critical for crisis intervention planning.
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A patient visiting the crisis clinic for the first time asks, 'How long will I be coming here?' The nurse's reply should consider that the usual duration of crisis intervention is how long in weeks?
- A. 1 to 2
- B. 3 to 4
- C. 4 to 6
- D. 6 to 12
Correct Answer: C
Rationale: The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks.
A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. What is the nurse's best initial statement to this patient?
- A. Everything is going to be all right. You are here at the clinic, and the staff will keep you safe.
- B. I see you are feeling upset. I am going to stay and talk with you to help you feel better.
- C. You need to try to stop crying so we can talk about your problems.
- D. Let's set some guidelines and goals for your visit here.
Correct Answer: B
Rationale: A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate the use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety. The incorrect responses use nontherapeutic techniques, including false reassurance and giving advice.
An adult seeks counseling after the spouse is murdered. The adult angrily says, 'I hate the monster that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict.' What is the nurse's highest priority question?
- A. What do you mean when you say 'monster'?
- B. What resources do you need to help you cope with this situation?
- C. Would you consider hurting yourself or the person on trial?
- D. Are you having thoughts of hurting yourself or others?
Correct Answer: D
Rationale: The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options may be important but not the highest priority.
Which situation demonstrates the use of primary care related to crisis intervention?
- A. Implementing suicide precautions for a patient with depression
- B. Teaching stress-reduction techniques to a beginning student nurse
- C. Assessing coping strategies used by a patient who has attempted suicide
- D. Referring a patient with schizophrenia to a partial hospitalization program
Correct Answer: B
Rationale: Primary crisis intervention promotes mental health and reduces mental illness, such as teaching stress-reduction techniques. Other options are secondary or tertiary interventions.
A woman says, 'I can't take anymore! Last year my husband was diagnosed with cancer. Three months ago, I lost my job. Yesterday my daughter said she's quitting college.' What is the nurse's priority assessment?
- A. Identifying measures useful to help improve the couple's communication
- B. Discussing the patient's feelings about the possibility of having a mastectomy
- C. Determining whether the husband is still engaged in an extramarital affair
- D. Clarifying what the patient means by 'I can't take it anymore!'
Correct Answer: D
Rationale: During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills, focusing on the most immediate stressor causing disequilibrium.