Which factor would the nurse identify first before assessing a childs response to a crisis Quizlet

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"Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."

Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking, "What do you mean, 'The whole thing is over'?" employs paraphrasing, but the message is blunt and closed-ended. In stating, "Over? Well, that sounds pretty drastic to me. Let's discuss this in the strictest confidence," the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating, "Can you tell me more about why it's over for you? I'll keep your thoughts strictly confidential," the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared.

"You talk about getting organized. Are you thinking of killing yourself?"

Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly "feeling so much better" and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming, "Good grief! You don't look organized to me," the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client's feelings. In asking, "Okay, what are you up to today? Your behavior is not appropriate," the nurse uses teasing to determine the client's behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating, "If you keep behaving like this, you know that I'll have to tell the doctor and we'll have to seclude you," the nurse uses a threat.

"You're feeling that your folks didn't want you, but they chose to marry and have you."

Rationale: In the correct option, the nurse uses reflection to explore the client's lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting, "You feel that you were a burden and not wanted? Let's talk with your parents to see whether you're right," the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, "Let's speak with your parents about what you've just told me. Let's ask whether you were truly unwanted," the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating, "Sounds like your father was very inappropriate, but I'm certain that he didn't mean that you were a burden to him," the nurse offers an opinion about the client's father and then provides false reassurance.

"You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?"

Rationale: The therapeutic response is the one that offers reflection, which permits the client to observe the content of what she is saying. In stating, "Of course, you can't be left alone to get on with what you want to do," the nurse makes a response that is social and belittles the client's feelings. In stating, "Okay, go ahead and do whatever you want to do. Human beings have free will," the nurse makes a response that seems sarcastic and angry; it is also judgmental and biased. In stating, "Sounds like you're angry with people for caring enough about you to try to keep you from hurting yourself," the nurse makes a premature judgment.

C "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police."

Rationale: Usually the volunteers on hotlines are trained to keep the client on the line, but in this case, the duty to warn the priest of the danger he is facing is paramount. When violence erupts, the nurse must think and act quickly and with clarity. "How did your dad learn of your abuse by clergy?" is off focus and inappropriate to the situation. Telling the client, "Call the police immediately and then call the priest to warn him that your dad has a gun," is incorrect, because the priest should be warned first. In stating, "You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened," the nurse does not focus on the imminent violence described in the question.

"Your husband is displaying behaviors that indicate a risk for self-harm."

Rationale: Risk factors for suicide include male gender, professional status (physician, attorney, dentist, military personnel), loss to death, financial problems, and physical illness. Other risk indicators include a suicide plan, depressed mood, and prior attempts at suicide. In stating, "Yes, he's too intelligent to end it all," the nurse provides false reassurance. In responding, "I'm not sure. I don't know him that well," the nurse may be accurate, but the answer avoids the client's concern. The statement "Most people who talk about ending it all are just looking for attention." is inaccurate. Any implication of suicide should be taken seriously.

"Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?"

Rationale: The therapeutic response is the one in which the nurse validates the client's drug-free time. In addition, in the correct option the nurse validates the client's self-assessment and supports and offers positive reinforcement. Finally the nurse begins to assess the client completely and attempts to identify precipitants. By stating, "Well, you really have had a good long drug-free time, but it sounds as if the doctor needs to reorder your medication at once," the nurse is premature in determining that the medication needs to be restarted; a thorough assessment must be performed first. In stating, "If you've been able to be drug free all this time, you probably don't need to restart the medicine. You probably just need some therapy to help you manage stress," the nurse jumps to giving advice and offering suggestions without performing a complete assessment. In stating, "Well, it's similar to when a client gets battered — things have to boil over before the police can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before the doctor can restart the medication," the nurse provides an incorrect statement and sarcastic information.

"This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."

Rationale: In most states (although the blood alcohol level, or BAL—designated as the indicator of intoxication—does vary), the legal alcohol limit is 0.08%. The most appropriate response is the one that teaches the client about his blood alcohol level and directs him to focus on his action and behaviors. In asking, "Did you ask the judge to clarify his decision to make you come here?" the nurse seeks clarification from the client, which closes off the expression of feelings by changing the focus of the discussion. In stating, "This reading means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level," the nurse gives inaccurate information about the BAL. In responding, "Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don't you agree?" the nurse gives opinions and is judgmental, then asks for agreement in a sarcastic style of communication.

"This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest."

Rationale: The most therapeutic nursing response is the one that expresses empathy and helps orient the client to reality. It also offers self, builds trust, and provides support for the client's distress. In asking, "Why not just throw him out yourself and lock up once and for all?" the nurse reinforces the hallucination and delusional thinking by responding as if the old man is really there. In stating, "Now, you know that you're always seeing things and people at night who aren't there," the nurse is patronizing and belittling in responding to the client's concerns, a nontherapeutic communication. In responding, "I'm sure that you're very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he'll leave your apartment," the nurse is lecturing the client and giving advice, which is not therapeutic.

"I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices."

Rationale: The most therapeutic nursing statement is the one in which the nurse addresses the client's behavior and asks whether the client is hearing voices. With this statement, the nurse also assesses the client's behavior. If the client is hearing voices, the nurse prevents reinforcement of the hallucinatory thinking by telling the client that he or she does not hear them. In asking, "Today is my birthday. Would you like to go on an outing with my family?" the nurse nontherapeutically changes the focus from the client. In stating, "You need to wash up and get ready to go to supper in the cafeteria with the other clients now," the nurse ignores the client's obvious psychotic behavior and directs the client to socialize with others. Such an intervention is not usually positive, because it floods the client with stimuli that may contribute to an escalation of psychotic behavior. In asking, "You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?" the nurse uses distraction, summarization, and refocusing.

"I can teach you strategies to help master your panic. An antianxiety medicine would also help you."

Rationale: A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance or actual avoidance of the object, activity, or situation. The nurse can teach strategies, such as relaxation training and thought-stopping, to help the client master her anxiety. There are also medications that the psychiatrist can prescribe to help ease the client's phobia. In stating, "No problem. You can be hypnotized to sleep through your trip," the nurse provides false reassurance and belittles the client's worries and fears. In responding, "I'm interested that it took his threat of leaving you to motivate you to seek help," the nurse uses a nontherapeutic change of subject that can only increase the client's anxiety and fear. This response also lowers the client's trust in her relationship with the nurse. In stating, "You seem more anxious and afraid of raising three children alone than of flying," the nurse changes the subject.

C "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move."

Rationale: In the correct option, the nurse employs the therapeutic communication technique of reflection, then offers a problem-solving strategy that will help improve the client's peripheral vision. In stating, "No one ever gets used to that thing! It's horrible," the nurse provides a social response that contains emotionally charged language and could increase the client's anxiety. In stating, "If I were you, I'd have had the surgery rather than suffer like this," the nurse undermines the client's faith in the medical treatment being used by giving advice that is insensitive and unprofessional. In asking, "Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don't you think?" the nurse uses excessive questioning and gives advice, both of which are nontherapeutic.

"Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."

Rationale: The therapeutic nursing statement is the one that educates the client and also debunks the myth, held by the client, that taking milk thistle excuses drinking. In stating, "Milk thistle aside, you still need to stop using alcohol. You have a severe drinking problem," the nurse denies the benefits of milk thistle (Silybum marianum) by avoidance and preaches to the client about alcoholism, which is nontherapeutic when the client is in denial. In asking, "If milk thistle is so effective, I wonder why the liquor industry isn't lobbying to put it in alcohol?" the nurse uses sarcasm and absurdity, both of which are nontherapeutic. In stating, "Milk thistle is used in Europe this way, but research findings are limited, so I'd stop drinking if I had a problem like you do," the nurse uses sarcasm.

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