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An adult tells the nurse, 'I can't take anymore! My mother passed away, my husband lost his job and yesterday my daughter told me she's quitting college and moving in with her boyfriend.' What is the priority nursing diagnosis?
- A. Fear, related to impending breast surgery
- B. Deficient knowledge, related to breast lesion
- C. Ine efectiva coping, related to perceived loss of daughter
- D. Impaired verbal communication, related to spousal estrangement
Correct Answer: C
Rationale: This nursing diagnosis reflects the precipitating event (daughter's actions) causing the crisis. Other options are not supported by the data provided.
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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.
A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event?
- A. Tell me why you were crying.
- B. How did your wrist get injured?
- C. How can I help you feel more comfortable?
- D. What was happening just before you started feeling this way?
Correct Answer: D
Rationale: A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking 'why' questions are a nontherapeutic communication technique.
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.
A woman says, 'I can't take anymore, and I have no children or husband to turn to! This last year has been one crisis after another.' If this person's immediate family is unable to provide sufficient situational support, what should the nurse do?
- A. Suggest hospitalization for a short period.
- B. Ask what other relatives or friends are available for support.
- C. Tell the patient, 'You must be strong. Don't let this crisis overwhelm you.'
- D. Foster insight by relating the present situation to earlier situations involving loss.
Correct Answer: B
Rationale: The assessment of situational supports should continue. Exploring other potential supports is appropriate before considering hospitalization. Advice and psychotherapy are not suitable for crisis intervention.
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.