ANS: D
The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 26-10, 42 (Table 26-3) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 7. Six months ago, a woman had a prophylactic double mastectomy because of a family history
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of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, “What else can happen?” What type of crisis is this person experiencing? a. Maturational b. Mitigation c. Situational d. Recurring ANS: C
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Severe physical or mental illness is a potential cause of a situational crisis. The potential loss of a loved one also serves as a potential cause of a situational crisis. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. Mitigation refers to attempts to limit a disaster’s impact on human health and community function.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 26-7, 8 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
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8. A woman said, “I can’t take anymore! Last year my husband had an affair and now we don’t
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ANS: D
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communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college.” What is the nurse’s priority assessment? a. Identify measures useful to help improve the couple’s communication. b. The patient’s feelings about the possibility of having a mastectomy c. Whether the husband is still engaged in an extramarital affair d. Clarify what the patient means by “I can’t take anymore.”
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During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 26-10, 42 (Table 26-3) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
9. Six months ago, a woman had a prophylactic double mastectomy because of a family history
of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman says tearfully, “What else can happen?” If the woman’s immediate family is unable to provide sufficient support, the nurse should a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support.
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