A 38-year-old female presents to urgent care. She has a 3-year-old and a 4-year-old child with her. She is frightened and badly bruised. "He'll kill us all if he knows we came here," she screams. What is the nurse's best response?
Bring her and her children to a room immediately
Ask her please not to scream-she is alarming the other patients
Ask, "Who will kill you?"
Ask her to sit for a moment while you contact someone who can provide safety for her.
The Correct Answer is A
A. Bring her and her children to a room immediately
This is a safety-first response. The woman is frightened and possibly in immediate danger. Moving her and the children to a private area provides physical and emotional safety and allows the nurse to continue assessment confidentially.
B. Ask her please not to scream-she is alarming the other patients
This is inappropriate and dismissive. Her distress signals potential abuse or trauma; silencing her prioritizes others’ comfort over her safety.
C. Ask, "Who will kill you?"
Although assessing threat is important, immediate safety must be ensured first before probing for more details.
D. Ask her to sit for a moment while you contact someone who can provide safety for her
Delaying action may increase the risk to her and her children. Immediate removal to a safe space is more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Stress:
Stress is the body’s nonspecific response to any demand for change. It can be physical, emotional, or psychological.
B. Anxiety:
Anxiety is a subjective emotional response, often a symptom of stress but not the physiological process itself.
C. Anger:
Anger is an emotional response to frustration or perceived threat, not a nonspecific body response to change.
D. Depression:
Depression is a mood disorder and not a general response to change.
Correct Answer is B
Explanation
A. Empathy:
Empathy is the ability to understand and share another person's feelings—not a form of anxiety.
B. Panic:
Panic is characterized by an acute onset of intense fear or terror, often accompanied by physiological symptoms like palpitations or shortness of breath.
C. Trauma:
Trauma refers to a deeply distressing or disturbing experience and may result in lasting effects, not necessarily a sudden feeling.
D. Crisis:
A crisis is a state of psychological disequilibrium, but panic is more immediate and physiologic in presentation.
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