What is the primary concern for a nurse assessing a client with signs of physical abuse?
Identifying the abuser and reporting to authorities.
Documenting all physical injuries comprehensively.
Determining if the client is in immediate danger or at risk for further harm.
Evaluating the client's mental health status
The Correct Answer is C
A. Identifying the abuser and reporting to authorities is important, but it is secondary to ensuring the client’s immediate safety. While reporting is required by law, the first priority in nursing care is assessing risk and preventing further harm.
B. Documenting all physical injuries comprehensively is necessary for legal and medical purposes, but it does not address the immediate safety risk, which takes precedence in acute assessment.
C. Determining if the client is in immediate danger or at risk for further harm is correct. In cases of physical abuse, the primary concern is the client’s safety. The nurse must quickly assess whether the client is at risk of ongoing harm and take appropriate steps, such as removing them from danger, initiating protective interventions, and contacting authorities if necessary. Safety assessment guides all subsequent interventions.
D. Evaluating the client’s mental health status is important for holistic care, but it is not the primary concern in acute situations of suspected physical abuse. Mental health assessment can follow once immediate safety is addressed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Voice tremors are typically associated with mild or moderate anxiety. In these cases, clients may exhibit nervousness, slight shakiness, or tremulous speech, but they retain rational thought and can still process information. Voice tremors alone do not indicate a panic state.
B. Shakiness is a physical symptom that often accompanies moderate anxiety. It reflects sympathetic nervous system activation—like increased heart rate or muscle tension—but the client can usually maintain focus and follow instructions.
C. Poor concentration also appears with mild to moderate anxiety, where stress may cause distraction or difficulty focusing, but clients are still capable of problem-solving and decision-making.
D. Depersonalization is a hallmark symptom of panic-level anxiety. It involves a sense of detachment from oneself or the environment, feelings of unreality, or as if one is observing themselves from outside their body. At this level, the client may also experience tunnel vision, distorted perceptions, palpitations, hyperventilation, chest pain, and fear of losing control or dying. Cognitive functioning is severely impaired, making it difficult for the client to communicate or follow directions.
Correct Answer is A
Explanation
A. Delusions are fixed, false beliefs that are not based in reality and are resistant to reasoning or contrary evidence. In this scenario, the client’s belief that a government agency is attempting to capture them is a persecutory delusion, which is a common type of psychotic symptom that can occur in severe depression with psychotic features.
B. Confusion refers to disorientation to person, place, or time and difficulty thinking clearly. The client’s statement reflects a specific false belief rather than generalized cognitive disorientation, so confusion is not the correct choice.
C. Inappropriate guilt involves excessive or unjustified feelings of responsibility or remorse, often seen in depression. The client’s statement is not about guilt or self-blame, making this option incorrect.
D. Mania is characterized by elevated mood, increased energy, decreased need for sleep, rapid speech, and impulsive behavior. The client’s persecutory belief does not indicate mania, so this option is incorrect.
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