A client presents to the primary care clinic pacing rapidly, wringing their hands, and hyperventilating. The client states, "My business partner just stole everything we had and vanished! I'm completely ruined. I can't think, I don't know how I'm going to tell my family." Which of the following initial nursing interventions are appropriate for this client? Select all that apply.
- Escort the client to a quiet, private environment and remain with them.Cevap
- Ask the client directly if they are having thoughts of self-harm or suicide.Cevap
- CProvide reassurance that law enforcement will likely apprehend the business partner.
- DEncourage the client to begin outlining a step-by-step financial recovery plan.
- Communicate using short, simple, and direct sentences.Cevap
Cevap
The appropriate initial interventions include staying with the client in a quiet environment, assessing for suicidal ideation, and using short, simple sentences.
During the acute phase of a situational crisis, the client exhibits severe anxiety, which drastically impairs problem-solving and cognitive processing. The immediate nursing priorities are establishing a safe environment, decreasing sensory overload, and communicating in a way the client can understand. Staying with the client in a quiet room provides safety and reduces stimulation. Directly assessing for suicidal ideation is a mandatory safety measure for a client experiencing a catastrophic loss. Using brief, directive communication is essential because the client's narrowed perceptual field prevents them from understanding complex sentences.
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Crisis Intervention: Acute Phase Prioritization