A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?
Assess risk for immediate harm.
Refer the client to a community support group.
Implement a safety plan.
Instruct the client on how to leave the relationship.
The Correct Answer is A
Choice A reason : The immediate safety of the client is the nurse's primary concern. Assessing the risk for immediate harm is crucial to prevent further abuse and to ensure the client's well-being. This involves evaluating the severity of the situation and the potential for future harm¹.
Choice B reason : While referring the client to a community support group is important for long-term support, it is not the immediate priority when a client reports abuse.
Choice C reason : Implementing a safety plan is a critical step, but it follows the initial assessment of immediate risk. The safety plan will be part of the ongoing support and intervention for the client.
Choice D reason : Instructing the client on how to leave the relationship is an important aspect of empowering the client; however, it is not the first action to take before assessing immediate risk and ensuring the client's safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : A sore throat is a common side effect of radiation therapy to the neck area, particularly for cancer of the larynx. The radiation can cause inflammation and irritation of the throat and laryngeal tissues, leading to pain and discomfort when swallowing¹⁵. This side effect can be managed with pain relief medications and dietary adjustments to include softer foods and liquids.
Choice B reason : Dry mouth, or xerostomia, occurs when radiation damages the salivary glands, reducing saliva production. This can lead to difficulties in speaking, tasting, chewing, and swallowing, as well as an increased risk of dental problems¹³. Patients undergoing radiation therapy are often advised to stay hydrated and may be prescribed saliva substitutes or stimulants.
Choice C reason : Radiation to the neck might damage the thyroid gland, leading to hypothyroidism. Symptoms of thyroid problems due to radiation can include fatigue, weight gain, feeling cold, and having dry skin or hair³. Regular monitoring of thyroid function is recommended for patients who have received radiation therapy in the neck area.
Choice D reason : Lymphedema is swelling that can occur when radiation therapy affects the lymph nodes and vessels, impeding the flow of lymph fluid. In the context of neck radiation, this can lead to swelling in the neck and face³. Management includes physical therapy, compression garments, and careful skin care to prevent infection.
Correct Answer is A
Explanation
Choice A reason : Serum creatinine is a key indicator of renal function. It is a waste product that kidneys filter out. Elevated levels can indicate impaired kidney function, which is a concern in SLE due to the risk of lupus nephritis².
Choice B reason : Urine-specific gravity can provide information about the kidney's ability to concentrate urine but is not as specific as serum creatinine for assessing overall renal function².
Choice C reason : Blood urea nitrogen (BUN) can be influenced by factors other than renal function, such as hydration status and dietary protein intake, making it less reliable than serum creatinine for evaluating kidney function in SLE².
Choice D reason : Serum sodium levels can be affected by various factors, including fluid balance and medications. While it can reflect changes in kidney function, it does not provide as direct an assessment as serum creatinine².
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