A nurse is implementing crisis intervention for a client following an incident of partner violence. Which of the following is the priority action for the nurse to take?

Help the client to identify effective past coping skills.

Initiate precautions to safeguard the client from physical harm.

Assist the client to identify available support systems.

Encourage the client to express feelings about the incident.

Answer and Explanation

The Correct Answer is B

A. Identifying past coping skills is important but is not the priority in a crisis situation where the client's safety is at risk.
B. Ensuring the client’s immediate safety is the priority because they may still be in danger from the abusive partner. Crisis intervention focuses first on protecting the client from further harm.
C. Identifying support systems is beneficial for long-term recovery but does not take precedence over ensuring the client’s immediate safety.
D. Encouraging expression of feelings is therapeutic, but the priority is to remove the client from immediate harm before addressing emotional needs.

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Correct Answer is D

Explanation

A. I will turn the car seat forward facing when my baby is 1 year old. This is incorrect because the American Academy of Pediatrics recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight limit specified by the car seat manufacturer.
B. I will place the retainer clip on my baby's upper abdomen. This is incorrect because the retainer clip should be positioned at armpit level to properly secure the straps and protect the baby in case of a collision.
C. I will position the shoulder harness straps 3 inches above my baby's shoulders. This is incorrect because for a rear-facing car seat, the shoulder harness straps should be positioned at or just below the infant’s shoulders, not above.
D. I will position my baby at a 45-degree angle in the car seat. This is correct because positioning the baby at a 45-degree angle helps maintain an open airway and prevents airway obstruction due to the head falling forward.

A. "You can expect to feel some pulsations in your neck during the procedure." B. "You'll wake up about 30 minutes after the procedure." C. "You might feel a bit confused for a few hours after the procedure." D. "You might notice some changes in your voice after the procedure."

Correct Answer is C

Explanation

A. Feeling pulsations in the neck is not an expected sensation during electroconvulsive therapy (ECT). The client is under general anesthesia and does not feel the procedure.
B. The client typically wakes up within 5 to 10 minutes after ECT, though they may remain drowsy for a while. 30 minutes is too long for initial awakening.
C. Post-procedure confusion and memory loss are common and temporary side effects of ECT, lasting a few hours to days in some cases.
D. Voice changes are not associated with ECT. The procedure does not affect the vocal cords or speech.

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A nurse is implementing crisis intervention for a client following an incident of partner violence. Which of the following is the priority action for the nurse to take?

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Naxlex Comprehensive Predictor Exams

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