A client who was mugged attends his third crisis intervention therapy session and reports that he has lost 10 pounds, cannot sleep, and feels very low. He ruminates about the possibility of being at fault for the mugging
The priority action the nurse should take is:
1. Hospitalize the client for protection of the self and others
2. Refer for assessment for antidepressant therapy
3. Discuss his blamelessness with him
4. Suggest dietary supplements
ANS: 2
Crisis intervention therapists are very active in therapy, making referrals and suggestions for cop-ing strategies. In this case the nurse would recognize the client's symptoms as suggesting depres-sion. Antidepressant medication is used in crisis therapy when symptoms suggest it is necessary; thus the nurse would refer the client to a physician or nurse practitioner with prescriptive privi-leges for evaluation for medication therapy. 1. Hospitalization is not necessary unless suicidal ideation is present. 3. The topic should be discussed, but if the ruminations are due to depression, simple discussion may not change his thinking. 4. This is appropriate, but it is not the priority.
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