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 A

Explanation

A. Suctioning device – Correct. A suctioning device is essential to clear the airway in case of excessive secretions during or after a seizure.

B. Bite block – Incorrect. Bite blocks are not used during seizures as they can cause injury. Nothing should be placed in the client’s mouth during a seizure.

C. Vest restraint – Incorrect. Restraints should not be used on clients with seizure disorders as they can cause injury.

D. Padded tongue blade – Incorrect. Tongue blades should never be inserted into the mouth of a seizing client due to the risk of airway obstruction and oral trauma.

A. Influenza B. Hepatitis A C. Varicella D. Rotavirus

Correct Answer is D

Explanation

A. Influenza – The first dose of the influenza vaccine is recommended at 6 months, not 2 months.

B. Hepatitis A – Hepatitis A vaccine is typically given at 12-23 months, not at 2 months.

C. Varicella – The varicella (chickenpox) vaccine is given at 12-15 months, so it is not appropriate for a 2-month-old.

D. Rotavirus – This is the correct answer. The rotavirus vaccine is recommended at 2 months, 4 months, and possibly 6 months, depending on the vaccine brand used.

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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

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