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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Crispy foods like rice bars can be difficult to swallow and increase the risk of aspiration.
B. Dry foods such as soda crackers require excessive chewing and can be a choking hazard.
C. This is the correct answer. Scrambled eggs have a soft, moist texture that is easy to chew and swallow, making them a good option for clients with dysphagia.
D. Peanut butter is thick and sticky, making it difficult to swallow and increasing aspiration risk.
Correct Answer is D
Explanation
A. A client who had a right hemisphere stroke – While a stroke may cause weakness on one side, BP measurements can still be taken unless there are additional contraindications like lymphedema or a fistula.
B. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm – BP should never be taken on the arm with an AV shunt, but this does not mean the right arm is unavailable.
C. A client who had blood drawn from the right antecubital area 1 hr ago – Blood draws do not typically affect BP measurements significantly unless there is excessive bruising or infiltration.
D. A client who has a right peripherally inserted central catheter (PICC) – Correct. Blood pressure cuffs can cause compression on the PICC line, leading to catheter occlusion, displacement, or thrombosis. The nurse should instruct the AP to use the opposite arm.
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