A nurse is implementing crisis interventions for a client following an incidence of intimate partner abuse. 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.
The Correct Answer is B
A. Help the client to identify effective past coping skills – While important, this is not the priority in a crisis situation.
B. Initiate precautions to safeguard the client from physical harm – Ensuring immediate safety is the top priority for a client in crisis. If the client is at risk of further harm, protective measures must be implemented.
C. Assist the client to identify available support systems – This is an important step but comes after ensuring safety.
D. Encourage the client to express feelings about the incident – Emotional support is important, but physical safety takes precedence in crisis situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Chvostek’s sign is associated with hypocalcemia, not lithium toxicity.
B. Lithium does not increase potassium levels; it may cause mild hyponatremia.
C. Lithium is more commonly associated with diarrhea, not constipation.
D. Lithium can cause nephrogenic diabetes insipidus, leading to increased urinary output.
Correct Answer is C
Explanation
A. Data comparison should be done after establishing the standards and collecting data.
B. While data collection is important, the first step is to determine what the accepted hand hygiene standards are.
C. This is the correct answer. The first step in an audit process is to determine the accepted hand hygiene standards to provide a basis for evaluation.
D. Corrective measures should only be taken after data has been collected and analyzed.
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