Chapter 13 Flashcards
A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis?
This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.
A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, “I can’t function any longer under all this stress.” Which type of crisis is the client experiencing?
Psychiatric emergency crisis
A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this client’s crisis?
The client will return to previous adaptive levels of functioning by week 6.
A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client?
Risk for self-directed violence R/T hopelessness
After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?
“Are you currently thinking about harming yourself?”
An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior?
With staff support and a show of solidarity, set firm limits on the behavior.
A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met?
“I carry mace when I jog. It makes me feel safe and secure.”
A despondent client, who has recently lost her husband of 30 years, tearfully states, “I’ll feel a lot better if I sell my house and move away.” Which nursing reply is most appropriate?
“This may not be the best time for you to make such an important decision.”
An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression?
The client has a tense facial expression and body language.
What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being “taken down” after a violent outburst?
To process feelings and concerns related to the witnessed intervention
Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply.
A. “Tell me what happened.”
B. “What coping methods have you used, and did they work?”
C. “Describe to me what your life was like before this happened.”
D. “Let’s focus on the current problem.”
E. “I’ll assist you in selecting functional coping strategies.”
A, B, C
Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply.
A. Maintain a calm demeanor.
B. Clearly delineate the consequences of the behavior.
C. Use therapeutic touch to convey empathy.
D. Set limits on the behavior.
E. Teach the client to avoid “I” statements related to expression of feelings.
A, B, D
