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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason : In primary hypothyroidism, the thyroid gland is underactive and does not produce sufficient thyroid hormones. As a result, the pituitary gland releases more TSH to stimulate the thyroid, leading to elevated levels of TSH in the blood⁶⁷⁸.

Choice B reason : Free T3 levels might not be elevated in primary hypothyroidism. Free T3 is the active form of triiodothyronine and could be normal or low depending on the severity and type of hypothyroidism⁶.

Choice C reason : Serum T3 levels are typically not the first indicator to change in primary hypothyroidism and may remain within normal ranges even when TSH is elevated⁶.

Choice D reason : Serum T4 levels are expected to be low in primary hypothyroidism because the thyroid gland is not producing enough of this hormone. However, the initial and most sensitive indicator of primary hypothyroidism is an elevated TSH level⁶.

A. Serum creatinine B. Urine-specific gravity C. Blood urea nitrogen (BUN) D. Serum sodium

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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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?

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Naxlex Comprehensive Predictor Exams

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