A clinic nurse is assessing a client who is experiencing crisis. The nurse needs to determine the client's immediate needs. Which is the priority action by the nurse?
A) Scan for physical distress.
B) Explore perceptions of the crisis.
C) Develop a follow-up plan.
D) Assess for immediate safety needs.
Answer: D
Assessing for immediate safety needs would take priority. An example of this would be a client coming into the clinic in crisis because she was violently abused by a significant other. It would be imperative for the nurse to determine the immediate safety needs of the client before proceeding. Scanning for physical distress and exploring perceptions of the crisis are important, but do not take priority over safety. Developing a follow-up plan would occur only after other interventions have been implemented.
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