The nurse is caring for a client in the emergency department (ED) after an assault by the spouse. The client has a history of similar emergency visits. Which action best assists the client?

Provide guidance to identify triggering behaviors.

Develop a plan for initiating a rapid exit.

Advise couple's counseling as the next step.

Complete a Patient Health Questionnaire-9 (PHQ9).

Answer and Explanation

The Correct Answer is B

A. Provide guidance to identify triggering behaviors: While identifying triggering behaviors can be helpful for future prevention, the immediate priority is ensuring the client’s safety. This is effectively achieved through a rapid exit plan, especially in cases of repeated assaults.

B. Develop a plan for initiating a rapid exit: The highest priority is ensuring the client's safety. A rapid exit plan, which involves knowing how to leave the abusive situation quickly and safely, is essential for protecting the client from immediate harm and planning for their long-term safety.

C. Advise couple's counseling as the next step: While counseling may be useful later, it is not appropriate to suggest it immediately after an assault. The client’s safety is the priority, and counseling should not be recommended until the client is in a safe environment.

D. Complete a Patient Health Questionnaire-9 (PHQ9): The PHQ9 is useful for assessing depression, but the immediate priority is addressing the client's safety and planning for protection, which should come before assessing for mental health concerns.

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Correct Answer is D

Explanation

A. This gene is passed down only to male children: An X-linked dominant inheritance disorder can be passed to both male and female children. are at risk for inheriting an X-linked dominant gene, but they are not the only offspring who can inherit the gene.

B. This gene is passed down only to female children: X-linked dominant inheritance disorders can be passed to both male and female children. Sons inherit the X chromosome from their mother, and daughters inherit one X chromosome from each parent.

C. There is a 100% chance of passing this gene on to all children: A 100% chance of passing the gene does not occur in X-linked inheritance disorders. In heterozygous conditions, the mother has a 50% chance of passing the gene to each child, whether male or female.

D. There is a 50% chance of passing this gene on to all children: In X-linked dominant inheritance, a heterozygous mother has a 50% chance of passing the gene to each child, regardless of the child’s sex.

A. Place an ice glove on the episiotomy for 20 minutes. B. Visualize the perineum and check the episiotomy. C. Administer the prescribed PRN analgesic. D. Instruct the client on the use of a sitz bath.

Correct Answer is B

Explanation

A. Place an ice glove on the episiotomy for 20 minutes: Ice can help reduce swelling and pain, but it is more appropriate as a secondary action after assessing the area. The nurse should first evaluate the condition of the episiotomy before deciding on the best intervention.
B. Visualize the perineum and check the episiotomy: The first step is to assess the episiotomy site to check for any signs of infection, excessive swelling, or other complications that might be causing the pain. This allows the nurse to determine the most appropriate treatment.
C. Administer the prescribed PRN analgesic: Administering pain medication may help alleviate discomfort, but it is essential to first evaluate the episiotomy site to rule out any potential issues before addressing the pain.
D. Instruct the client on the use of a sitz bath: A sitz bath can be helpful for comfort, but the nurse should first assess the episiotomy site to ensure there are no complications requiring immediate attention before recommending this intervention.

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The nurse is caring for a client in the emergency department (ED) after an assault by the spouse. The client has a history of similar emergency visits. Which action best assists the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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