Crisis Theory and Intervention

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?

The nurse is conducting an initial assessment of a client in crisis. When assessing the client’s perception of the precipitating event that led to the crisis, which is the most appropriate question?

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?

The nurse in the emergency department is caring for a young female victim of sexual assault. The client’s physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors?

A depressed client on an inpatient unit says to the nurse, “My family would be better off without me.” Which is the nurse’s best response?

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply.

1. Initiate confinement measures.
2. Acknowledge the client’s behavior.
3. Assist the client to an area that is quiet.
4. Maintain a safe distance from the client.
5. Allow the client to take control of the situation.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action?

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, “I’m finally cured.” Based on the client’s behavior and statement, which intervention should the nurse include in the plan?

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions?

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels “as though the rape just happened yesterday,” even though it has been a few months since the incident. Which is the most appropriate nursing response?

A client is admitted t the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.

1. “I’m afraid of spiders.”
2. “I keep reliving the robbery.”
3. “I see his face everywhere I go.”
4. “I don’t want anything to eat now.”
5. “I might have died over a few dollars in my pocket.”
6. “I have to wash my hands over and over again many times.”