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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Providing the client with written information about privacy laws is a good practice, but a verbal explanation is also necessary to address the immediate concern.
B. This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk.
C. Non-verbal gestures may be ambiguous and could lead to misunderstandings. It's important to communicate clearly with the client.
D. Assuring the client that information will be shared only with the staff may not be entirely accurate, as there are situations where confidentiality must be breached, such as when safety is a concern.

A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever. B. Place the client in protective isolation for the first two weeks of treatment with this medication. C. Offer this medication to the client with food to decrease the possibility of gastric upset. D. Report findings from the client’s weekly white blood cell (WBC) counts to the healthcare provider.

Correct Answer is D

Explanation

A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

Correct Answer is B

Explanation

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Correct Answer is D

Explanation

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