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 should be familiar with what information about this type of crisis?
- This type of crisis is precipitated by unexpected external stressors.
- This type of crisis is precipitated by preexisting psychopathology.
- This type of crisis is precipitated by an acute response to an external situational stressor.
- This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.
Rationale: 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.
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?
- Maturational/developmental crisis
- Psychiatric emergency crisis
- Anticipated life transition crisis
- Traumatic stress crisis
Rationale: 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 an inability to assume personal responsibility.
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 long-term outcome is realistic in addressing this client’s crisis?
- The client will change his type A personality traits to more adaptive ones by one week.
- The client will list five positive self-attributes.
- The client will examine how childhood events led to his overachieving orientation.
- The client will return to previous adaptive levels of functioning by week six.
Rationale: The nurse should identify that a realistic long-term outcome for this client is to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect immediacy of the situation.
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?
- Ineffective coping R/T situational crisis AEB powerlessness
- Anxiety R/T fear of failure
- Risk for self-directed violence R/T hopelessness
- Risk for low self-esteem R/T loss events AEB suicidal ideations
Rationale: The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client or others.
After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?
- “Are you currently thinking about harming yourself?”
- “Why do you want to harm yourself?”
- “Have you thought about the consequences of your actions?”
- “Who is your emergency contact person?”
Rationale: The nurse should first assess the client for current harmful or suicidal thoughts to minimize risk of harm to the client and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency in which the crisis team should assess for client safety as a priority.
An involuntarily committed client when offered a dinner tray pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior?
- Initiate forced medication protocol.
- Help the client to explore the source of anger.
- Ignore the act to avoid reinforcing the behavior.
- With staff support and a show of solidarity, set firm limits on the behavior.
Rationale: The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor should not warrant forced medication. This intervention may be too restrictive, considering the behavior. Exploring the source of anger may be more appropriate once the client has resolved the current emotion or in a therapeutic group setting. Ignoring the act may further upset the client and is not a method of teaching appropriate behavior.
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?
- “You’ve really been helpful. Can I count on your for continued support?”
- “I work out in the college gym rather than jogging outdoors.”
- “I’m really glad I didn’t go home. It would have been hard to come back.”
- “I carry mace when I jog. It makes me feel safe and secure.”
Rationale: The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. The final phase of crisis intervention involves evaluating the outcome of the crisis intervention and anticipatory planning.
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?
- “I’m confident you know what’s best for you.”
- “This may not be the best time for you to make such an important decision.”
- “Your children will be terribly disappointed.”
- “Tell me why you want to make this change.”
Rationale: 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.
An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression?
- The client requests prn medications.
- The client has a tense facial expression and body language.
- The client refuses to eat lunch.
- The client sits in group with back to peers.
Rationale: 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 history of violence and develop interventions for de-escalation.
What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place on an inpatient unit?
- Reinforce unit rules with the client population.
- Create protocols for the future release of tensions associated with anger.
- Process client feelings and alleviate fears of undeserved seclusion and restraint.
- Discuss the situation that led to inappropriate expressions of anger.
Rationale: The nurse should determine that the purpose for holding a debriefing session with clients and staff after a take-down intervention is to discuss the situation that led to inappropriate behavior. It is important to determine the factors leading to the inappropriate behavior in order to develop future intervention strategies. It is also important to help clients and staff process feelings about the situation.
An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation?
- An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 1 hour of the initiation of the restraints.
- An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 2 hours of the initiation of the restraints.
- An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 3 hours of the initiation of the restraints.
- An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 4 hours of the initiation of the restraints.
Rationale: The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) requires that an in-person evaluation by physician or other licensed independent practitioner be conducted within 1 hour of the initiation of restraint or seclusion.
A combative adolescent client has been placed in seclusion after all other interventions have failed. Which protocol would apply in this situation?
- The physician or other licensed independent practitioner must reissue a new order for restraints every 24 hours.
- The physician or other licensed independent practitioner must reissue a new order for restraints every 8 hours.
- The physician or other licensed independent practitioner must reissue a new order for restraints every 3 to 4 hours.
- The physician or other licensed independent practitioner must reissue a new order for restraints every 1 to 2 hours.
Rationale: The physician or other licensed independent practitioner must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents. Restraints should be used as a last resort, after all other interventions have been unsuccessful, and the client is clearly at risk of harm to self or others.
A nursing instructor is teaching about the Roberts’ Seven-Stage Crisis Intervention Model. Which nursing action should be identified with Stage IV?
- Collaboratively implement an action plan.
- Help the client identify the major problems or crisis precipitants.
- Help the client deal with feelings and emotions.
- Collaboratively generate and explore alternatives.
Rationale: The following are the stages of the Roberts’ Seven-Stage Crisis Intervention Model:
Stage I: Psychosocial and Lethality Assessment, Stage II: Rapidly Establish Rapport, Stage III: Identify the Major Problems or Crisis Precipitants, Stage IV: Deal with Feelings and Emotions, Stage V: Generate and Explore Alternatives, Stage VI: Implement an Action Plan, Stage VII: Follow-up.`
Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.)
- “Tell me what happened.”
- “What coping methods have you used, and did they work?”
- “Describe to me what your life was like before this happened.”
- “Let’s focus on the current problem.”
- “I’ll assist you in selecting functional coping strategies.”
ANS: 1, 2, 3
Rationale: 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 would not occur until after a complete assessment.
Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)
- Maintain a calm demeanor.
- Clearly delineate the consequences of the behavior.
- Use therapeutic touch to convey empathy.
- Set limits on the behavior.
- Teach the client to avoid “I” statements related to expression of feelings.
ANS: 1, 2, 4
Rationale: The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, 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 increase the client’s anger. Teaching would not be appropriate when a client is agitated.
Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.)
ANS: 1, 3, 5
Rationale: The Broset Violence Checklist is a quick, simple, and reliable tool that can be used to assess the risk of potential violence. The behavior assessment categories include: confusion, irritability, boisterousness, physical threats, and verbal threats.