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?

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

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?

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?

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.)

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.)

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?

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.)

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?

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?

Accepted Answer

The sudden onset of extreme fatigue, decreased sleep, and decreased appetite, along with a high anxiety rating, suggest that the client may be experiencing symptoms of a mood disorder, such as depression or anxiety. It is unlikely that the client will be able to change long-standing personality traits or fully examine and resolve childhood events in the short term. Therefore, the most realistic long-term outcome is to return to previous adaptive levels of functioning by week six, which is a reasonable timeframe for medication and therapy to take effect.

Question 12

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 response is most appropriate?

Accepted Answer

It is generally advised to avoid making major life decisions during periods of intense grief, as emotions can cloud judgment. The nurse's response should gently guide the client to consider delaying such decisions until she is in a more stable emotional state.

Question 13

Which nursing action would be identified with Stage IV of Roberts' Seven-stage Crisis Intervention Model?

Accepted Answer

Stage IV of Roberts' Seven-stage Crisis Intervention Model involves helping the client deal with feelings and emotions.

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?

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?

Accepted Answer

The priority nursing diagnosis for this client is Risk for self-directed violence R/T hopelessness. This diagnosis takes precedence over the other options because the client has attempted suicide and is therefore at immediate risk for harming herself again. The other options address important issues, but they are not as urgent as ensuring the client's safety.

Quiz 9: Crisis Intervention