The assumption that will be most useful to the nurse planning crisis intervention for any client who
is experiencing a crisis is that the client
a. is experiencing a type of mental illness.
b. is experiencing a state of disequilibrium.
c. has high potential for self-injury.
d. poses a threat of violence to others.
B
The only answer universally true for all clients in crisis is option B. A crisis represents a struggle for
equilibrium when problems seem unsolvable. Option A: Crisis does not reflect mental illness.
Options C and D: Potential for self-violence or other-directed violence may or may not be factors in
crisis.
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A) Vital signs B) Behavior C) Affect D) Awareness
A patient declared brain dead after cardiac surgery has been accepted as a potential donor. The family has given consent for donation. The nurse providing care to this patient would expect directions from which provider?
1. Organ procurement organization (OPO) coordinator 2. Surgeon 3. Cardiologist 4. Hospitalist
The nurse is providing care to a client who is on strict intake and output. The client drank 12 ounces of orange juice at breakfast. How many mL will the nurse document for this meal as intake?
1. 160 mL 2. 260 mL 3. 360 mL 4. 460 mL
An industrial unit in which the employees regularly handle heavy machinery has employed a nurse. Which intervention is most relevant for the nurse in this work environment?
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