The crisis nurse working with law enforcement is called to assist at a scene where an overtly psychotic individual is threatening officers with a handgun. He shouts that aliens dressed like police are pursuing him and he has to get away
The priority intervention is:
1. Screen for the level of psychiatric care needed
2. Assist the client to make sense of the experience
3. Evaluate the client for recent substance use
4. Ensure the client's safety and develop rapport
ANS: 4
Clients who feel threatened should be assured of their safety so that rapport building can take place. When rapport has been developed, the nurse may be able to convince the individual to give up any weapons. Options 1 and 3 are relevant, but they are not primary. Option 2 may not be possible if the client is under the influence of a drug or is experiencing delusions or hallucina-tions.
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