A nurse in an emergency department is caring for a client following an assault. Which of the following actions should the nurse take first?

Provide information to the client about local support groups.

Ask the client how they have dealt with stress in the past.

Determine if the client is experiencing thoughts of self-harm

Schedule a follow up visit with the client's primary provider.

Answer and Explanation

The Correct Answer is C

A. Provide information to the client about local support groups: While this is helpful, it is not the first priority. The client's immediate safety and emotional well-being must be addressed first, especially to rule out any thoughts of self-harm or suicidal ideation.

B. Ask the client how they have dealt with stress in the past: While understanding past coping strategies is important, the first priority should be assessing for immediate risks, such as thoughts of self-harm, before discussing past coping mechanisms.

C. Determine if the client is experiencing thoughts of self-harm: This is the first priority. After an assault, clients are at increased risk for self-harm or suicide. The nurse must assess for these thoughts immediately to ensure the client's safety.

D. Schedule a follow-up visit with the client's primary provider: Scheduling follow-up care is important, but it is not the first step. Immediate assessment for safety, including thoughts of self-harm, should take precedence.

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Correct Answer is B

Explanation

A. Institute consequences for deliberate behaviors: While consequences can help manage behaviors, focusing on punishment alone is not the most effective approach for ADHD. Positive reinforcement is often more beneficial.
B. Encourage thought stopping techniques: Thought-stopping techniques help children with ADHD manage impulsive behaviors and improve focus. They teach self-regulation by interrupting unwanted thoughts.
C. Administer olanzapine: Olanzapine is an a typical antipsychotic, not a treatment for ADHD. Stimulants like methylphenidate or amphetamines are typically used for ADHD management.
D. Provide a stimulating environment: A stimulating environment can worsen distractions for children with ADHD. A structured, quiet environment helps improve focus and reduces impulsivity.

A. Ensure the client's room is dark at night B. Use symbols to assist the client in finding personal items C. Ask the client orientation questions many times per day. D. Provide a high level of sensory stimulation during the day.

Correct Answer is B

Explanation

A. Ensure the client's room is dark at night: A dark room can increase confusion and agitation in clients with dementia, especially at night. It’s important to provide a well-lit environment to reduce confusion and help the client maintain a sense of orientation.
B. Use symbols to assist the client in finding personal items: Using symbols, pictures, or labels to help the client identify personal items can provide orientation and reduce frustration. This approach supports independence while minimizing confusion.
C. Ask the client orientation questions many times per day: Asking orientation questions repeatedly can increase anxiety and confusion for clients with dementia. It’s more effective to provide reassurance and support rather than focusing on constant questioning of orientation.
D. Provide a high level of sensory stimulation during the day: While some level of stimulation is important, excessive sensory input can overwhelm or agitate a client with dementia. The environment should be calm and soothing to avoid overstimulation.

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A nurse in an emergency department is caring for a client following an assault. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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