An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?
Tell the client to call Adult Protective Services if his son’s abuse continues.
Verify the client’s report by determining if there is physical evidence of abuse.
Refer the client to a program for victims of domestic violence.
Assist the client in developing an emergency safety plan.
The Correct Answer is D
A. Telling the client to call Adult Protective Services is a valid intervention, but immediate safety planning is crucial.
B. Verifying the client's report by determining physical evidence is important but may not be the most immediate and practical intervention.
C. Referring the client to a program for victims of domestic violence is a valuable option, but immediate safety planning should take precedence.
D. Assisting the client in developing an emergency safety plan is the most important intervention to ensure the client's safety in the present situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Level of activity, interactions with others, and appetite are important aspects, but the emotional quality of attitude is central in assessing the effectiveness of an antidepressant.
Changes in mood and affect are critical indicators of the drug's impact on the client's mental health.
B. Interactions with others provide valuable information but may not capture the internal emotional experience of the client.
C. The emotional quality of attitude reflects the client's internal state and is a key indicator of the antidepressant's impact on their depressive symptoms.
D. Appetite is a relevant aspect, but it may not be as direct an indicator of the antidepressant's efficacy as changes in the emotional quality of attitude.
Correct Answer is ["A","B","D"]
Explanation
Rationale for A: Reinforcing a will to live and encouraging realistic future plans can promote hope and motivation in a depressed adolescent.
Rationale for B: Discussing the client’s suicide plan is essential for assessing risk and ensuring safety. It allows for intervention if the risk is significant.
Rationale for C: While managing screen time can be beneficial, it is less critical than addressing the underlying emotional issues and ensuring safety.
Rationale for D: Encouraging the client to express thoughts and feelings about wanting to die can provide a safe space for the adolescent to discuss suicidal ideation and help the nurse assess risk more effectively.
Rationale for E: Restricting visitors may not be helpful; maintaining social connections can provide support and reduce feelings of isolation.
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