Nokea
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.
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A woman says, 'I can't take anymore! Last year my husband had an affair. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college.' What type of crisis is this person experiencing?
- A. Maturational
- B. Adventitious
- C. Situational
- D. Recurring
Correct Answer: C
Rationale: A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. The series of events described, particularly the daughter's decision, points to external stressors.
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 scenario is an example of an adventitious crisis?
- A. Death of a child from sudden infant death syndrome
- B. Being fired from a job because of company downsizing
- C. Retirement of a 55 year old
- D. A riot at a rock concert
Correct Answer: D
Rationale: An adventitious crisis is unplanned and violent, like a riot. Other options represent situational or maturational crises.
An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, 'I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?' Which nursing diagnosis applies?
- A. Hopelessness
- B. Powerlessness
- C. Chronic low self-esteem
- D. Disturbed thought processes
Correct Answer: B
Rationale: The patient's statements reflect a lack of control over life events, indicating powerlessness. Other diagnoses are not supported by the data.
After completing the contracted number of visits to the crisis clinic, an adult says, 'I've emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I'm benefiting from a support group.' The nurse can evaluate the patient's feelings about the care received as what?
- A. Marginally satisfied
- B. Somewhat satisfied
- C. Moderately satisfied
- D. Very satisfied
Correct Answer: D
Rationale: The patient's positive statements about strength, support, and resources indicate a high level of satisfaction.