Question 1

A client is brought to an emergency department by police after threatening to jump off a bridge several hours ago. To assess for suicide potential, which question would a nurse ask first?&#10;A) &#34;Are you currently thinking about harming yourself?&#34;&#10;B) &#34;Why do you want to harm yourself?&#34;&#10;C) &#34;Have you thought about the consequences of your actions?&#34;&#10;D) &#34;Who is your emergency contact person?&#34;&#10;

Accepted Answer

The first question a nurse would ask to assess for suicide potential would be whether the client is currently thinking about harming themselves. This is a direct and important question to assess the client's immediate risk.

Question 2

A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse would note that this type of crisis is precipitated by

A) Unexpected external stressors.
B) Preexisting psychopathology.
C) An acute response to an external situational stressor.
D) Normal life-cycle transitions that overwhelm the client.

Accepted Answer

This situation describes a normal life-cycle transition, in this case, becoming a new parent, which can overwhelm the client. The mother's anxiety and ambivalence about her new role and leaving the postpartum unit indicate she is struggling with the adjustments and responsibilities that come with parenthood, a common experience during significant life changes.

Question 3

An involuntarily committed client purposely pushes a dinner tray off the bedside table onto the floor. Which nursing intervention would a nurse implement to address this behavior?&#10;A) Initiate forced medication protocol.&#10;B) Help the client to explore the source of anger.&#10;C) Ignore the act to avoid reinforcing the behavior.&#10;D) With staff support, set firm limits on the behavior.&#10;

Accepted Answer

Setting firm limits on the behavior is the appropriate nursing intervention for a client who purposely exhibits disruptive behavior. This should be done with the support of the staff to ensure safety and adherence to facility policies. Forcing medication, ignoring the behavior or exploring the source of anger without addressing the behavior itself may not address the situation directly and can potentially escalate the situation.

Question 4

A sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem, can be defined as a ______.

Accepted Answer

The answer of A sudden event in one's life that...

Question 5

An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior would alert a nurse to escalating anger and aggression?&#10;A) The client requests prn medications.&#10;B) The client has a tense facial expression.&#10;C) The client refuses to eat lunch.&#10;D) The client sits in group with back to peers.&#10;

Accepted Answer

Pacing is a sign of anxiety and agitation and can also be a precursor to violent behavior. A tense facial expression can indicate that the client is becoming more agitated and angry, which may result in a violent outburst. The other options are not necessarily related to escalating anger and aggression. The client may request prn medications for various reasons, and refusing to eat lunch or sitting with their back to peers may not necessarily indicate escalating aggression.

Question 6

Which nursing statements or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.)&#10;A) &#34;Tell me what happened.&#34;&#10;B) &#34;Which coping methods have you used, and did they work?&#34;&#10;C) &#34;Describe to me what your life was like before this happened.&#34;&#10;D) &#34;Let's focus on the current problem.&#34;&#10;E) &#34;I'll assist you in selecting functional coping strategies.&#34;&#10;

Accepted Answer

The answer of Which nursing statements or questions represent appropriate...

Question 7

Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.)&#10;A) Confusion&#10;B) Paranoia&#10;C) Boisterousness&#10;D) Panic&#10;E) Irritability&#10;

Accepted Answer

The Broset Violence Checklist includes categories such as confusion, boisterousness, and irritability to assess the risk of violence.

Question 8

Which describes the rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place in an inpatient unit?&#10;A) Reinforce unit rules with the client population.&#10;B) Create protocols for the future release of tensions associated with anger.&#10;C) Process client feelings and alleviate fears of undeserved seclusion and restraint.&#10;D) Discuss the situation that led to inappropriate expressions of anger.&#10;

Accepted Answer

The answer of Which describes the rationale for holding a...

Question 9

Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)&#10;A) Maintain a calm demeanor.&#10;B) Clearly delineate the consequences of the behavior.&#10;C) Use therapeutic touch to convey empathy.&#10;D) Set limits on the behavior.&#10;E) Teach the client to avoid &#34;I&#34; statements related to expression of feelings.&#10;

Accepted Answer

A) Maintaining a calm demeanor can help de-escalate the situation and prevent the client from becoming more agitated.

B) Clearly delineating the consequences of the behavior can help the client understand the impact of their actions and encourage them to consider more appropriate ways of expressing anger.

C) While therapeutic touch can be helpful in many situations, it may not be appropriate for all clients and may not be effective in managing anger.

D) Setting limits on the behavior can help the client understand what is expected of them and what will not be tolerated.

E) Teaching the client to avoid "I" statements related to the expression of feelings may be helpful in some situations but may not be effective for all clients experiencing anger issues. It is generally more helpful to teach clients how to express their emotions in a healthy and productive way.

Question 10

A wife brings her husband to an emergency department (ED) 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?

A) Maturational/developmental crisis
B) Psychiatric emergency crisis
C) Anticipated life transition crisis
D) Traumatic stress crisis

Accepted Answer

The client is experiencing a psychiatric emergency crisis as he has made a suicidal attempt and is in need of immediate treatment and support.

Question 11

A client comes to a psychiatric clinic experiencing sudden extreme fatigue, decreased sleep, and decreased appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. Which long-term outcome is realistic in addressing this client's crisis?

A) The client will change his type-A personality traits to more adaptive ones within one week.
B) The client will list five positive self-attributes.
C) The client will examine how childhood events led to his overachieving orientation.
D) The client will return to previous adaptive levels of functioning by week six.

Accepted Answer

The answer of A client comes to a psychiatric clinic...

Question 12

A despondent client who has recently lost her husband of 30 years tearfully states, &#34;I'll feel a lot better if I sell my house and move away.&#34; Which nursing response is most appropriate?&#10;A) &#34;I'm confident you know what's best for you.&#34;&#10;B) &#34;This may not be the best time for you to make such an important decision.&#34;&#10;C) &#34;Your children will be terribly disappointed.&#34;&#10;D) &#34;Tell me why you want to make this change.&#34;&#10;

Accepted Answer

The answer of A despondent client who has recently lost...

Question 13

Which nursing action would be identified with Stage IV of Roberts' Seven-stage Crisis Intervention Model?&#10;A) Collaboratively implement an action plan.&#10;B) Help the client identify the major problems or crisis precipitants.&#10;C) Help the client deal with feelings and emotions.&#10;D) Collaboratively generate and explore alternatives.&#10;

Accepted Answer

The answer of Which nursing action would be identified with...

Question 14

A college student, who was nearly raped while out 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?

A) "You've really been helpful. Can I count on you for continued support?"
B) "I work out in the college gym rather than jogging outdoors."
C) "I'm really glad I didn't go home. It would have been hard to come back."
D) "I carry mace when I jog. It makes me feel safe and secure."

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Accepted Answer

The answer of A college student, who was nearly raped...

Question 15

A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client?

A) Ineffective coping R/T situational crisis AEB powerlessness
B) Anxiety R/T fear of failure
C) Risk for self-directed violence R/T hopelessness
D) Risk for low self-esteem R/T loss events AEB suicidal ideations

Accepted Answer

The answer of A high school student has learned that...

Deck 9: Crisis Intervention