An ambulatory care nurse is assessing a caregiver who arrived with a 4-week-old infant for a scheduled immunization visit. The caregiver is trembling, crying profusely, and states, 'I cannot handle this. I have not slept in almost a week, the baby will not stop screaming, and I am a complete failure.' Which of the following initial interventions by the nurse are appropriate? Select all that apply.
- Ask the caregiver directly about any thoughts of self-harm or harming the infant.Answer
- Validate the caregiver's feelings by stating, 'It sounds like you are feeling incredibly overwhelmed right now.'Answer
- Inquire about the availability of family members or friends who can immediately assist the caregiver.Answer
- DReassure the caregiver by stating, 'It is completely normal to feel this way, and things will get better soon.'
- EProceed with the infant's scheduled immunizations before addressing the caregiver's distress.
Answer
The appropriate initial interventions are to directly assess for thoughts of self-harm or harm to the infant, validate the caregiver's feelings to establish a therapeutic connection, and assess the availability of immediate support systems.
During an acute crisis, the nurse's first priority is always safety, making it essential to explicitly assess for any thoughts of harm to self or others. Once immediate safety is assessed, the nurse must use therapeutic communication techniques, such as validation and active listening, to build trust and help de-escalate the situation. Additionally, identifying immediate support systems is a critical component of crisis intervention to help the client manage the overwhelming stressors.
Step-by-Step Solution
Key Concept
In crisis intervention, the nurse's initial priorities are to ensure the safety of the client and dependents, establish a therapeutic relationship using empathetic communication, and assess the client's immediate support systems.