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","B","C","E","F"]
Explanation
Choice A reason : Morphine sulfate is used intravenously in acute heart failure with pulmonary edema because it can reduce preload and afterload, thereby decreasing the work of the heart and improving breathing.
Choice B reason : Administering oxygen is crucial for a client with pulmonary edema to improve oxygenation and relieve symptoms of hypoxia.
Choice C reason : Transporting the client to the coronary care unit is appropriate for continuous monitoring and management of acute heart failure and pulmonary edema.
Choice D reason : While placing the client in a high Fowler's position is recommended to ease breathing, the low Fowler's side-lying position is not typically indicated for pulmonary edema. Therefore, this choice is incorrect.
Choice E reason : Inserting a Foley catheter can help monitor urine output, especially important when administering diuretics like furosemide, and manage fluid status.
Choice F reason : Administering furosemide (Lasix), a diuretic, helps to reduce fluid overload and relieve pulmonary congestion in clients with heart failure and pulmonary edema.
Correct Answer is B
Explanation
Choice A reason : Benzodiazepines are not typically used for the long-term treatment of obsessive-compulsive disorder due to the risk of dependence and because other medications, such as SSRIs, are more effective for long-term management⁵.
Choice B reason : Benzodiazepines are effective for the short-term management of panic attacks due to their rapid onset of action, which can quickly alleviate acute symptoms of anxiety and panic⁵⁹.
Choice C reason : Long-term treatment of agoraphobia generally involves psychotherapy and SSRIs or SNRIs rather than benzodiazepines, which can lead to dependence and are not recommended for long-term use⁵.
Choice D reason : Benzodiazepines are not the first-line treatment for depression and are generally not used for this purpose. Antidepressants and psychotherapy are the standard treatments for depression⁵.
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