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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
- A. Protecting the client from injury.
- B. Determining the cause of the client’s anxiety.
- C. Ensuring that the client feels safe.
- D. Identifying the client’s coping skills.
Correct Answer: A
Rationale: The correct answer is A: Protecting the client from injury. This is the highest priority because ensuring the client's physical safety takes precedence in a crisis situation. If the client is at risk of harming themselves or others, immediate action must be taken to prevent injury. Determining the cause of anxiety, ensuring the client feels safe, and identifying coping skills are important but secondary priorities once the client's safety is assured. In a crisis situation, physical safety is paramount before addressing underlying causes or providing emotional support.
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A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
- A. "Because you are a minor, I have to share any information that I feel is important with your parents."
- B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
- C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
- D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
Correct Answer: B
Rationale: Duty to warn applies when a client expresses intent to harm others, requiring disclosure to the care team.
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?
- A. "I can arrange for a female assistive personnel to do your personal hygiene care."
- B. "The nurse assigned to care for you is very capable and cares for other women in this situation."
- C. "Your doctor is a man, so it seems like this should not be a problem."
- D. "I can review the assignments and arrange for a female nurse to care for you."
Correct Answer: D
Rationale: The correct answer is D. The nurse manager should respect the client's wishes and arrange for a female nurse to care for her. This is important for the client's comfort and sense of safety. Option A only addresses personal hygiene care, not overall nursing care. Option B focuses on the nurse's capabilities, not the client's preferences. Option C is dismissive of the client's concerns and does not address the issue directly. It is essential to prioritize the client's feelings and choices in this sensitive situation.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
- A. Grooming
- B. Long-term memory
- C. Support systems
- D. Affect
- E. Presence of pain
Correct Answer: A, B, D
Rationale: The correct choices for the nurse to include in the MSE for a client with dementia are A, B, and D. Grooming is important to assess the client's self-care ability, which can be impacted by dementia. Long-term memory is essential in evaluating cognitive decline typically seen in dementia. Affect assessment helps determine emotional responses and can indicate changes in mood associated with dementia. Support systems (choice C) are not typically part of the MSE but are relevant for treatment planning. Presence of pain (choice E) is important but not a traditional component of a mental status examination.
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
- A. Implement the client's behavioral modification plan.
- B. Document the size and location of the cuts.
- C. Assess the client's intent and suicide risk.
- D. Administer a tetanus antitoxin.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h