A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the bestresponse by the nurse?

Question

Quizplus · Accepted Answer

This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident"). When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion. Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness. Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event. Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress. (Option A) Assessing this family's support system is important. However, it is not the priority action at this time. (Option B) This statement does not address what this client's spouse is experiencing at the moment. At a later time, the nurse can explore the client's history and any events that may have lead to this situation. (Option D) This response does not address the spouse's concerns. Also, the wording is judgmental and nontherapeutic. Educational objective: Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.

A Client Is Brought to the Emergency Department After the Spouse