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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.
B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.
C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.
D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.
Correct Answer is A
Explanation
Rationale:
A. Evaluate the client's coping skills: Secondary prevention focuses on early identification and prompt intervention to prevent worsening of a condition. Assessing the client’s coping skills helps the nurse identify maladaptive behaviors or psychological distress early, allowing for timely referral or intervention.
B. Explore the client's desired goals: Exploring future goals is tertiary prevention, which aims at restoring function and promoting long-term adaptation after a life event. While important, it does not address immediate detection or intervention needs during an acute phase.
C. Discuss available support systems with the client: This is a supportive and therapeutic action, but it is part of tertiary prevention, which promotes recovery and prevents further decline. It is not as immediate or diagnostic as evaluating current coping abilities.
D. Ensure the safety of the client: Ensuring client safety is always a priority if there is any indication of harm or suicidal ideation. However, if no imminent safety risk is present, it does not serve as the main focus of secondary prevention, which emphasizes early detection and screening.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.