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. "This surgery can cause an increase in the amount of semen.":A transurethral resection of the prostate (TURP) often results in retrograde ejaculation, meaning semen may flow backward into the bladder. The volume of visible semen typically decreases, not increases, due to this common complication.
B. "I will talk to my partner about other ways of expressing intimacy.":This statement reflects healthy psychological adjustment and understanding of potential changes in sexual function following TURP. It shows emotional readiness to adapt to changes and maintain intimacy in ways beyond penetrative sex, which supports recovery and relationship stability.
C. “I will not be able to have sexual intercourse after this surgery.":TURP does not prevent sexual intercourse. While temporary issues like erectile dysfunction or retrograde ejaculation may occur, most clients can resume sexual activity after recovery. This belief represents a misunderstanding of surgical outcomes.
D. “This surgery will prevent me from being able to have an erection.": Although some men may experience temporary erectile dysfunction postoperatively, TURP typically does not cause permanent loss of erectile function. Misconceptions about impotence should be addressed through accurate education.
Correct Answer is A
Explanation
Rationale:
A. "My advance directives will list what treatments I want if I'm unable to communicate.": Advance directives allow individuals to specify their healthcare preferences in situations where they are incapacitated. This includes decisions about life-sustaining treatments, resuscitation, and other medical interventions.
B. "My advance directives must be signed by my adult child in the presence of a judge.": Advance directives usually require the client’s signature and the signatures of two adult witnesses or notarization, depending on state laws. A judge’s involvement is typically not required.
C. "My family will be informed about my funeral choices in my advance directives.": Funeral or postmortem arrangements are not addressed in advance directives. These documents strictly relate to medical care preferences and decision-making in the event the client becomes unable to speak for themselves.
D. “I can indicate the organs will donate in my advance directives.": While some advance directive forms may include a section about organ donation, formal organ donor registration is typically completed through a driver’s license, organ donor card, or state registry—not as the main purpose of an advance directive.
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