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 B

Explanation

A. Allergic. Symptoms of an allergic reaction to a blood transfusion typically include itching, rash, and hives rather than chills, headache, or low-back pain.
B. Acute hemolytic. This reaction occurs when the client receives incompatible blood, leading to red blood cell destruction. Symptoms include chills, headache, low-back pain, chest tightness, hypotension, and fever.
C. Bacterial. A bacterial transfusion reaction is usually caused by contaminated blood products and presents with fever, chills, hypotension, and possible sepsis. The described symptoms suggest a different reaction.
D. Febrile nonhemolytic. This reaction is more common and presents with fever, chills, and headache but does not typically include low-back pain or chest tightness, which are more indicative of an acute hemolytic reaction.

A. Wire cutters B. Padded clamp C. Montgomery straps D. Tracheostomy tray

Correct Answer is B

Explanation

A. Wire cutters. This is incorrect because wire cutters are used for clients with wired jaws in case of an emergency but are not needed for chest tube management.
B. Padded clamp. This is correct because a padded clamp is necessary in case the chest tube needs to be momentarily clamped for troubleshooting air leaks or before removal.
C. Montgomery straps. This is incorrect because Montgomery straps are used to secure frequent dressing changes, such as for abdominal wounds, and are not relevant to chest tube management.
D. Tracheostomy tray. This is incorrect because a tracheostomy tray is used for clients at risk for airway obstruction, which is not a routine need following a thoracotomy with chest tube placement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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