Practice Question
A 56-year-old male was brought to the ED via personal vehicle. The chief complaint is hallucinations, intrusive traumatic thoughts and memories, and self-harm. The client has multiple broken bones, contusions, and abrasions and has exposed bones in his hands as he continuously punched a mirror in his home. Morphine 2 mg IV for pain has been given hourly for the past 3 hours. He just received his next dose. Dr. Seager has set his fingers as best he could, and we are waiting for the orthopedic surgeon's consultation to arrive and determine if surgery is needed. The client is resting comfortably in his room with a sitter until his risk for suicide is determined. Which nursing intervention is most appropriate in caring for this client at this time?
Answer Choices:
Correct Answer:
Establish trust and provide safety and stabilization through a safe and predictable environment.
Rationale:
🟦 Client shows acute psychological distress, suicidality risk, and self-harm → requires immediate safety and stabilization.
🟦 Safety and predictable environment help reduce anxiety and prevent further harm.
🟦 Establishing trust is the foundational intervention in trauma and crisis stabilization.
🟦 Before education or therapy, the nurse must ensure environmental control, monitoring, and supportive presence.
🟦 Aligns with priority of suicide precautions, sitter monitoring, and crisis de-escalation.
Diazepam PO
🟦 Giving sedatives in severe trauma without full assessment can worsen respiratory depression with concurrent morphine use.
🟦 Does not address immediate need for psychological safety.
Informational pamphlets
🟦 Client is in acute crisis, unable to process written material.
🟦 Education is not a priority during instability.
Educate about negative impacts of self-harm
🟦 Not therapeutic in crisis; can increase shame and guilt.
🟦 Could escalate distress rather than stabilize.
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This question is from Examplify Level 2 Test 4 Version A (Tuesday) Fall25 which contains 49 questions.
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From Exam
Examplify Level 2 Test 4 Version A (Tuesday) Fall25
49 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 4