A nurse is caring for a client who has an injury related to partner violence. The client does not want to report the incident to the authorities or leave their home. Which of the following actions should the nurse take first?

Ask the client to describe the incident.

Assist the client with developing a safety plan.

Provide the client with information about local shelters.

Refer the client to a support group.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Ask the client to describe the incident: The first step is to gather detailed and accurate information about what happened. This not only allows the nurse to assess the severity and risk of harm but also builds trust with the client. Understanding the specifics of the situation is essential before planning further interventions.

B. Assist the client with developing a safety plan: While crucial for long-term well-being, safety planning should come after assessing the current situation. The nurse must first understand the context of the incident to tailor the plan effectively and ensure it aligns with the client’s readiness and safety.

C. Provide the client with information about local shelters: Offering shelter information is supportive and may be part of discharge or follow-up teaching. However, this should follow the initial assessment, as the client may not yet be ready to consider leaving or may have specific needs not met by general resources.

D. Refer the client to a support group: Support groups are helpful for emotional healing and connection but are not an immediate priority. Without understanding the client’s current circumstances, risk level, and readiness to engage, such a referral may not be appropriate at this stage.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Contact security personnel to place the money in the designated secure location: Hospitals have protocols for handling client valuables. The safest and most appropriate action is to notify security so the funds can be securely stored, documented, and returned appropriately. This maintains accountability and protects both the client and staff.

B. Label the money with the client's name and leave it at the nurses' station: Leaving valuables at the nurses' station, even if labeled, poses a risk for loss or theft. It does not meet institutional standards for safeguarding client property and may violate facility policies.

C. Place the money in an envelope in the client's medication drawer: Medication drawers are intended for storing prescribed medications only. Using them for valuables is inappropriate, insecure, and may lead to misplacement or confusion during care transitions.

D. Hold the money for the client until their return from surgery: Personally holding the client’s money is a liability and not an accepted protocol. It lacks formal documentation and security, increasing the risk of loss or accusation of theft.

A. Check for seals in the drainage system. B. Place a waterproof pad under the client's buttocks. C. Clip the drainage tubing to the edge of the mattress. D. Position the drainage bag below the level of the client's bladder.

Correct Answer is A

Explanation

Rationale:

A. Check for seals in the drainage system: Urinary leakage in a client with an indwelling catheter may indicate a break in the closed drainage system. Inspecting for disconnected or loose seals is essential to verify the system’s integrity and ensure proper catheter function, reducing the risk of backflow or infection.

B. Place a waterproof pad under the client's buttocks: This action addresses the symptom of leakage rather than identifying or correcting the cause. While it may help manage moisture, it does not ensure the catheter is functioning properly or prevent further complications.

C. Clip the drainage tubing to the edge of the mattress: Clipping the tubing can obstruct flow and increase the risk of urine retention or reflux. Tubing should be secured loosely and not kinked, with no tension that might disrupt drainage or lead to malfunction.

D. Position the drainage bag below the level of the client's bladder: While proper bag positioning is important to promote gravity drainage, it does not specifically verify safe functioning if leakage is occurring. Ensuring the drainage system is intact is the first step in evaluating catheter function.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has an injury related to partner violence. The client does not want to report the incident to the authorities or leave their home. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for surgery and discovers a large sum of money in the client's wallet. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has an indwelling urinary catheter and reports urinary leakage. Which of the following actions should the nurse take to verify the safe functioning of the urinary catheter?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has experienced a divorce. Which of the following priority actions should the nurse take to promote secondary prevention?

A nurse is using incident reports with a group of newly licensed nurses. The nurse should include in the discussion that which of the following situations requires completion of an incident report?

A nurse is contributing to the plan of care for a client who has a gambling disorder. Which of the following nursing interventions should the nurse include in the plan of care?

A nurse is assisting in the care of a client who is scheduled for surgery. Which of the following steps should the nurse take prior to witnessing informed consent?

A nurse is planning care for a client who is preoperative for a surgical procedure. The nurse should identify that which of the following tasks is outside of their scope of practice?

A nurse is preparing to administer a medication and is unfamiliar with the medication. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client and asks the client. "Can you tell me about your day so far?" Which of the following therapeutic techniques is the nurse using?

A nurse in a long-term care facility is making client care assignments for the unit. Which of the following tasks should the nurse assign to an assistive personnel?