An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict."
What is the nurse's highest priority response?
a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?"
b. "What resources do you need to help you cope with this situation?"
c. "Do you have enough support from your family and friends?"
d. "Are you having thoughts of hurting yourself or others?"
ANS: D
The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety.
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