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. Empty the collection chamber every 8 hr – Incorrect. The collection chamber is not emptied; instead, it is replaced when full to prevent air re-entry.
B. Check the patency of the tubing every 2 hr – While monitoring the tubing is essential, checking patency is not the most specific nursing priority.
C. Keep the drainage system above the level of the client's chest – Incorrect. The system should remain below chest level to prevent backflow of drainage.
D. Ensure 2 cm (0.8 in) of water is in the water seal chamber – Correct. The water seal chamber maintains negative pressure and prevents air from entering the pleural space, making this a crucial step in chest tube management.
Correct Answer is D
Explanation
A. Tachycardia – Digoxin toxicity typically causes bradycardia, not tachycardia, due to its effect on the AV node.
B. Hearing loss – Digoxin does not commonly cause hearing loss; ototoxicity is more associated with aminoglycoside antibiotics.
C. Insomnia – While some neurological symptoms may occur, insomnia is not a classic sign of digoxin toxicity.
D. Blurred vision – This is the correct answer. Digoxin toxicity can cause visual disturbances such as blurred vision, yellow-green halos, and scotomas. Other signs include nausea, vomiting, anorexia, fatigue, and cardiac arrhythmias.
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