NCLEX-RNPsychosocial IntegrityMedium
A client in the emergency department after a natural disaster is pacing, crying uncontrollably, and unable to answer simple questions about their name or location. Which nursing intervention is the priority?
- AAdminister an as-needed anxiolytic medication immediately.
- BProvide a calm, quiet environment and use short, simple directions.
- CRefer the client to a support group for disaster survivors.
- DEncourage the client to describe the traumatic event in detail.
Show answer & explanationAnswer & explanation
Correct answer: B. Provide a calm, quiet environment and use short, simple directions.
This client is in acute crisis with impaired cognitive functioning; the immediate priority is to reduce environmental stimuli and use simple, direct communication to help the client regain a sense of safety and orientation before other interventions can be effective.
Why the other options are wrong
- A. Medication should not be the first response without further assessment and is not always appropriate.
- C. Referral to a support group is a long-term intervention, not appropriate during acute crisis.
- D. Detailed recounting of trauma during acute crisis can worsen distress and is inappropriate at this time.
Acute Crisis Intervention
Immediate nursing care for a person in acute crisis focuses on ensuring safety, reducing stimuli, and using simple communication to restore a sense of control.
- Crisis impairs normal coping and cognitive processing
- Use short, simple sentences and calm tone
- Reduce environmental stimuli first
- Avoid in-depth trauma processing during acute phase
Memory trick: Calm the storm before you talk about it.