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.

Answer and Explanation

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.

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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.

A. Placental abruption B. Amniotic fluid embolus C. Placenta previa D. Uterine rupture

Correct Answer is A

Explanation

A. Placental abruption – This is the correct answer because placental abruption occurs when the placenta detaches prematurely from the uterine wall, leading to severe abdominal pain, vaginal bleeding, uterine rigidity, and signs of hypovolemic shock (low blood pressure). The hallmark sign is a painful, rigid abdomen with contractions.

B. Amniotic fluid embolus – This condition presents with sudden respiratory distress, hypotension, and disseminated intravascular coagulation (DIC), but it does not typically cause uterine rigidity or persistent contractions.

C. Placenta previa – Placenta previa typically presents with painless vaginal bleeding rather than severe abdominal pain and a rigid uterus.

D. Uterine rupture – Uterine rupture is usually associated with a history of uterine surgery (e.g., previous cesarean section). It presents with sudden, severe pain followed by cessation of contractions, not persistent contractions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols. Which of the following steps should the task force take first?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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