NCLEX · Crisis and Grief

A nurse following the crisis intervention model responds to a client who reports their spouse just left them and they feel there is no reason to live. Which approach is CORRECT?

Correct answer

Assess for suicidal ideation using direct questioning, implement safety measures as indicated, provide crisis support, and connect the client to additional resources — crisis intervention focuses on immediate stabilization, not long-term therapy

  1. A Tell the client to call back when they have calmed down
  2. B Assess for suicidal ideation using direct questioning, implement safety measures as indicated, provide crisis support, and connect the client to additional resources — crisis intervention focuses on immediate stabilization, not long-term therapy
  3. C Offer only general advice without safety assessment
  4. D Refer the client to a support group only

Why this is the answer

CRISIS INTERVENTION is a short-term, active approach designed to help an individual in a crisis reach an acceptable level of functioning. A CRISIS is a temporary state of disequilibrium in which the person's usual coping mechanisms are insufficient for the situation. PHASES OF CRISIS INTERVENTION (Roberts' 7-Stage Model): ASSESS lethality/safety (FIRST); establish RAPPORT and RELATIONSHIP; identify major PROBLEMS; explore FEELINGS and emotions; explore previous COPING; RESTORE cognitive functioning/generate alternatives; implement ACTION PLAN. DIRECT LETHALITY ASSESSMENT: ask DIRECTLY about suicidal thoughts — 'Are you thinking about hurting yourself?' (asking directly does NOT increase risk; it is therapeutic); if yes: assess PLAN (do they have a specific plan?), MEANS (access to method), INTENT (do they intend to carry it out), TIMELINE; PROTECTIVE FACTORS: children, pets, religious beliefs, social support, reasons for living. IMMEDIATE SAFETY MEASURES based on assessment: if imminent risk: call emergency services (911); if client is seen in person: do not leave alone; ensure environmental safety; if telephone call: maintain contact, get location, call 911; RESOURCES: National Crisis Line 988 (Suicide and Crisis Lifeline); crisis text line; local mental health crisis centers; emergency room. CRISIS CHARACTERISTICS: usually time-limited (4-6 weeks); represents both DANGER and OPPORTUNITY (some clients emerge with better coping skills); acute, not chronic; the person is in pain, not pathological. POST-CRISIS: connect to longer-term mental health resources; follow-up; acknowledge strength in reaching out.
Source: NCLEX-RN Test Plan: Psychosocial — Crisis Intervention