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A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first?

A.

Empower the client to feel that he is in charge of his life.

B.

Find the client a temporary shelter where he can feel safe.

C.

Determine if the client has thoughts about self-harm.

D.

Review the client's available social support system

Answer and Explanation

The Correct Answer is C

Choice A reason

Empowering the client to feel in charge of his life is essential for promoting coping and a sense of control over the situation. However, it may not be the first priority when the client's safety is in question.

Choice B reason:

Finding the client, a temporary shelter where he can feel safe is important for meeting the client's immediate physical needs, but it can be addressed after ensuring his emotional well-being and safety.

Choice C reason

The client's partner has died in a traumatic event, and the loss of both a loved one and their home can be emotionally overwhelming and distressing. The nurse's first priority should be to assess the client's safety and well-being, especially considering the potential for thoughts of self-harm or suicide.

Assessing for thoughts of self-harm is critical because the client may be experiencing intense grief, guilt, or hopelessness, which can increase the risk of self-harm or suicidal ideation. Identifying these thoughts early allows the nurse to initiate appropriate interventions, provide emotional support, and involve mental health professionals if necessary.

Choice D reason

Reviewing the client's available social support system is significant for addressing the client's emotional needs and establishing a support network. However, ensuring the client's safety takes precedence over this action.


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Related Questions

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.

Correct Answer is ["0.6"]

Explanation

To calculate the total volume to be administered each day:

  1. Dosage per administration: 30 mg
  2. Frequency: Every 12 hours (twice a day)
  3. Volume per administration: 0.3 mL (since 30 mg is in 0.3 mL)

The total volume per day is:

0.3mL×2=0.6mL

Therefore, the practical nurse should administer 0.6 mL each day.

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