Rhenis Nursing Rhenis Nursing
Examplify Med-Surg Level-2 Test-4 Version A
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1 :

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 Options

Hint : 🎯Focus first on what keeps the patient and everyone else safe right now.

Correct Answers:

  • Establish trust and provide safety and stabilization through a safe and predictable environment.


Rationale :

🛡️Immediate priorities in acute crises with hallucinations and risk of self-harm are safety, stabilization, and trust-building, which reduce arousal and prevent further injury.

🧭A structured, predictable milieu (clear limits, calm tone, sitter, suicide precautions) helps decrease anxiety and disorganization, making assessment and care possible.

🧩Therapeutic alliance enhances cooperation with pain control, surgical consults, and psychiatric evaluation, supporting holistic, trauma-informed care.

🔒Education or pamphlets can follow later, but initial interventions must first control risk and provide psychological and environmental containment.

📌Core Message

Safety, stabilization, and trust come first in acute psychiatric–medical crises; education or long-term strategies wait until risk is controlled.

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