Question 1

Which of the following interventions should the nurse utilize when caring for an inpatient client who is expressing anger inappropriately? Select all that apply.

Accepted Answer

When caring for an inpatient client who is expressing anger inappropriately, the nurse should maintain a calm demeanor, clearly delineate the consequences of the behavior, and set limits on the behavior. A calm demeanor can help deescalate the situation and prevent further anger. Clearly delineating the consequences of the behavior can help the client understand the impact of their actions and potentially reduce the behavior in the future. Setting limits on the behavior can also help prevent the behavior from escalating and ensure the safety of the client and others. Using therapeutic touch may not be appropriate for all clients and teaching the client to avoid "I" statements may not be effective in managing anger.

Question 2

After threatening to jump off a bridge,a client is brought to an emergency department by police.Which question should the nurse ask first to assess for suicide potential?

Accepted Answer

This direct question can help assess the client's current suicidal ideation and potential intent to harm themselves. It is important to address this first before delving into other aspects of the client's mental health or situation.

Question 3

An involuntarily committed client,when offered a dinner tray,pushes it off the bedside table onto the floor.Which is the nurse's priority intervention?

Accepted Answer

Setting firm limits on the behavior is the most appropriate intervention as it establishes clear boundaries and consequences for the behavior. It is important to maintain a safe environment for everyone involved and demonstrate that the behavior is not acceptable. Initiating forced medication protocol is not appropriate in response to this behavior, and helping the client to explore the source of anger may be important in the long term but should not be the priority in this situation. Ignoring the behavior could lead to reinforcement of the behavior, as it may be seen as a way to gain attention or a desired outcome.

Question 4

A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse.Which client statement,made at the final session,most clearly suggests the goals of crisis intervention have been met?

Accepted Answer

Choice D suggests that the client has taken steps to feel safe and secure during future jogs. This indicates that the crisis intervention has helped the client move from a state of crisis to a more stable and empowered state.

Question 5

A despondent client who 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?

Accepted Answer

The nurse should gently advise the client that making major decisions during a period of grief may not be wise, as emotions can cloud judgment.

Question 6

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.Which long-term outcome is realistic to address the client's crisis?

Accepted Answer

The client is experiencing symptoms of exhaustion and anxiety due to overwork and stress. To address this crisis, the primary goal should be to help the client return to previous adaptive levels of functioning, which would involve reducing anxiety, improving sleep and appetite, and adjusting work schedule. Changing personality traits, listing positive self-attributes, or examining childhood events may be useful interventions in the long-term, but they are unlikely to address the immediate crisis. Therefore, option D is the most realistic long-term outcome for the client's crisis.

Question 7

An inpatient client with a known history of violence suddenly begins to pace.Which client behavior alerts the nurse to the client's escalating anger and aggression?

Accepted Answer

Pacing, along with tense facial expression and body language, can suggest the client's escalating anger and aggression. The other options do not necessarily indicate an escalation of anger and aggression.

Question 8

Which of the following are most appropriate when performing a nursing assessment with an individual in crisis? Select all that apply.

Accepted Answer

The answer of Which of the following are most appropriate...

Question 9

Which 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?

Accepted Answer

Holding a debriefing session after clients have witnessed a peer being "taken down" after a violent outburst is important to process the feelings and concerns related to the witnessed intervention. This can help the clients cope with any distress or trauma caused by the incident and promote healing within the group. The other answer choices do not address the immediate need for psychological support and processing of emotions after witnessing a traumatic event.

Question 10

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?

Accepted Answer

This type of crisis is related to normal life-cycle transitions, such as becoming a new mother, which can overwhelm the client if they feel unprepared or unable to cope with the new responsibilities and changes. It is not necessarily due to unexpected external stressors, preexisting psychopathology, or an acute response to an external situational stressor, but rather the normal transitions and adjustments in life that can sometimes be challenging.

Question 11

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

Accepted Answer

The priority nursing diagnosis for this client is Risk for self-directed violence R/T hopelessness as the client has already attempted suicide by overdosing on Tylenol. This is the most urgent issue that needs to be addressed to ensure the safety of the client. The other options may also be appropriate but addressing the risk for self-directed violence takes precedence.

Question 12

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?

Accepted Answer

The husband's attempt to hang himself and his statement about not being able to function under stress indicate a psychiatric emergency crisis. This type of crisis involves acute, severe disturbances in thinking, mood, or behavior that require immediate intervention to prevent harm to the individual or others.

Quiz 13: Crisis Intervention