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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. "Rest in supine position for 30 minutes after a meal.": Lying flat after a meal increases the risk of aspiration particularly in stroke clients who may have impaired swallowing. A more upright position should be encouraged during and after meals to reduce this risk.

B. "Dress the affected side first.": Dressing the affected side first promotes independence and makes the task easier by minimizing the need for fine motor coordination on the impaired side. It also reduces frustration and helps establish a safe, consistent dressing routine.

C. "Use the arm on your affected side to brush your hair.": Stroke often leads to muscle weakness or paralysis on one side, making it difficult or unsafe to perform tasks with the affected limb. Initially, clients should use their stronger arm while the affected side is supported and rehabilitated gradually.

D. "Use a straw when you drink liquids.": Using a straw can increase the risk of aspiration in clients with post-stroke dysphagia by promoting rapid fluid intake. It is generally contraindicated until a swallowing assessment confirms that it is safe.

A. Seeking clarification B. Reflecting C. Focusing D. Giving broad openings

Correct Answer is D

Explanation

Rationale:

A. Seeking clarification: Seeking clarification involves asking the client to explain something they have already said to ensure mutual understanding. It usually occurs in response to ambiguous or unclear statements, not as an initial, open-ended invitation to speak.

B. Reflecting: Reflecting is a technique in which the nurse restates the client’s feelings or thoughts to encourage deeper exploration. The nurse in this case is not restating anything but is instead prompting the client to share independently.

C. Focusing: Focusing involves guiding the conversation toward a specific topic or detail the client has already brought up. Since the nurse is initiating a broad and open-ended question, focusing is not the technique being used here.

D. Giving broad openings: This technique encourages the client to take the lead in the conversation by expressing themselves freely. Asking this question invites open communication and helps build rapport, which is characteristic of broad opening statements.

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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

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Correct Answer is D

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