Examkin

Question

Difficulty: HardCrisis Intervention

A home care nurse is conducting an initial visit with a 68-year-old client whose spouse was permanently transitioned to a dementia care center just hours ago. The client is pacing rapidly around the empty house, crying uncontrollably, and remarks, "I betrayed my vow to keep them at home. I am completely worthless now. There is simply no point in me waking up tomorrow without them here." Which of the following is the priority nursing action?

  1. Determine whether the client has formulated a specific plan to end their life.Answer
  2. B
    Validate the client's profound feelings of guilt and offer a supportive presence.
  3. C
    Explain that the care center can provide the specialized medical supervision the spouse requires.
  4. D
    Investigate the coping strategies the client relied upon during previous family crises.

Answer

The priority action is to determine whether the client has formulated a specific plan to end their life.
During a severe situational crisis, the client's emotional distress can precipitate self-harm. The client's statement, "There is simply no point in me waking up tomorrow," is a strong indicator of potential suicidal ideation. During any crisis intervention, ensuring client safety is always the absolute highest priority. Before implementing broad psychological support, rationalizing the event, or exploring past coping strategies, the nurse must explicitly assess the lethality and specificity of the client's thoughts of self-harm.

Step-by-Step Solution

1
Analyze the client's verbal statements for covert or overt safety risks.
The phrase "There is simply no point in me waking up tomorrow" is a significant cue indicating potential suicidal ideation.
Recognizing safety threats is the first step in clinical prioritization during a crisis.
2
Apply the principles of crisis intervention and clinical prioritization.
Client safety outranks all other interventions, including emotional validation, psychological stabilization, and assessment of coping skills.
According to Maslow's Hierarchy of Needs and standard safety protocols, preservation of life is the foundational priority.
3
Select the nursing action that directly addresses the highest priority need.
The action that directly assesses the lethality and presence of a suicide plan is the correct choice.
Direct assessment of self-harm intent allows the nurse to immediately implement life-saving precautions if necessary.

Key Concept

Crisis Intervention: Prioritizing Client Safety
Rate this question

Topics

Crisis Intervention

More questions from this topic