Question 1

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.

Accepted Answer

The nurse should determine that when working with an inpatient client who expresses anger inappropriately,it is important to maintain a calm demeanor,clearly define the consequences,and set limits on the behavior.The use of therapeutic touch may not be appropriate and could escalate the client's anger.

Question 2

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?

Accepted Answer

The priority nursing diagnosis for this client is "Risk for self-directed violence R/T hopelessness." Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others.Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential.

Question 3

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?

Accepted Answer

The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning.The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation.To be correctly written,an outcome must be client-centered,specific,measurable,realistic,and contain a time frame.

Question 4

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?

Accepted Answer

The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention.

Question 5

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?

Accepted Answer

The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken down" after a violent outburst is to process feelings and concerns related to the witnessed intervention.

Question 6

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?

Accepted Answer

During crisis intervention,the nurse should guide the client through a problem-solving process.The nurse should help the individual confront the source of the problem,encourage the individual to discuss changes he or she would like to make,and encourage exploration of feelings about aspects of the crisis that cannot be changed.The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate.This response encourages the client to think through what may be an impulsive decision.

Question 7

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 nurse should determine that the client is experiencing a psychiatric emergency crisis.Psychiatric emergencies occur when crisis situations result in severe impairment,incompetence,or inability to assume personal responsibility.

Question 8

Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply.

Accepted Answer

In the assessment phase,the nurse should gather information regarding the precipitating stressor and the resulting crisis.Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments.

Question 9

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?

Accepted Answer

The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions.A suicidal client is experiencing a psychiatric emergency.The crisis team should prioritize safety by assessing the client for thoughts of self-harm.

Question 10

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?

Accepted Answer

The most appropriate nursing intervention is to set firm limits on the behavior.Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern.Exploring the source of anger may be appropriate after the client has gained emotional control.Ignoring the act may further upset the client and does not reinforce appropriate behavior.

Question 11

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

The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.Reassurance and guidance should be provided as needed,and the client should be referred to services that can provide assistance.

Question 12

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?

Accepted Answer

The nurse should assess that tense facial expressions and body language may indicate that a client's anger is escalating.The nurse should conduct a thorough assessment of the client's past and current violent behaviors and develop interventions for de-escalation.

Quiz 13: Crisis Intervention