in financial status, divirce, the addition of
Ensure that the security officer is within
a new family members, pregnancy and
severe illness. Options A,B and D identify
adventitious crisis. An adventitious crisis
is not part of everyday life, is unplanned
and accidental.
28. A nurse is gathering a data from a crisis.
When determining the client’s perception of
the precipitating event that led on the crisis,
the most appropriate question to ask is:
a. “What leads you to seek help now?”
b. “Who is available to help you?”
c. “What do you usually do to feel better?”
d. “With whom do you live?”
29. A nurse is assisting in developing a plan of
care for the client in crisis state. When
developing plan, the nurse will consider
which of the following?
a. Presenting symptoms in a crisis situation
are similar for all individuals experiencing
a crisis
b. A crisis states indicates that the individual
is suffering from emotional illness
c. A crisis state indicates that the individual
is suffering from a mental illness
d. A client’s response to a crisis for one
person may not constitute a crisis for
another person
30. A nurse observes that the client with a
potential for violence is agitated, pacing up
and down the hallway, and is making
aggressive belligerent gestures at the other
clients. Which of the following statements
would be the most appropriate to make to
this client?
a. “What is causing you to become
agitated?”
b. “You need to stop that behavior now!”
c. “You will need to be restrained if you
don’t change your behavior”
d. “You will need to place in seclusion”
31. A nurse is planning care for a client who is
being hospitalized because the client has
been displaying violent behavio and is at risk
for potential harm to others. Which of the
following would not be a component of the
plan of care?
a. Keep the door to the client’s room open
when with the client
b. Assign the client to a room at the end of
the hall
c. Face the client when providing care
St. Louis Review Center, Inc-Davao Tel. no. (082) 224-2515 or 222-8732
d.
the immediate area
28. Answer A
A nurse’s initial task when gathering data
from a client in crisis is to assess the
individual or family and the problem. The
more clearly the problem can be defined,
the better the chance a solution can be
found. Option A will assist in determining
data related to the precipitating event that
led on the crisis. Option B and D identify
situational supports. Option C identifies
personal coping skills.
29. Answer D
Although each crisis response can be
described in similar terms as far as
presenting symptoms are concerned,
what constitutes a crisis from one person
may not constitute a crisis for another
person because each is a unique
individual. Being in crisis state does not
mean that the client is suffering from an
emotional or mental illness.
30. Answer A
The best statement is to ask the client
what is causing the agitation. This will
assist the client to become aware of the
behavior and will assist the nurse in
planning appropriate interventions for the
client. Option B is demanding behavior,
which could cause increased agitation to
the client. Options C and D are threats to
the client and are inappropriate.
31. Answer B
The client should be placed in a room
near the nurses station and not at the end
of a long, relatively unprotected corridor.
The nurse should not isolate self with a
potentially violent client. The door to the
client’s room should be kept open, and
the nurse should never turn away from
the client. A security officer or male aide
should be within immediate call if there is
a suspicion that an act of violence is
imminent.
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