A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?
Assess risk for immediate harm.
Refer the client to a community support group.
Implement a safety plan.
Instruct the client on how to leave the relationship.
The Correct Answer is A
Choice A reason : The immediate safety of the client is the nurse's primary concern. Assessing the risk for immediate harm is crucial to prevent further abuse and to ensure the client's well-being. This involves evaluating the severity of the situation and the potential for future harm¹.
Choice B reason : While referring the client to a community support group is important for long-term support, it is not the immediate priority when a client reports abuse.
Choice C reason : Implementing a safety plan is a critical step, but it follows the initial assessment of immediate risk. The safety plan will be part of the ongoing support and intervention for the client.
Choice D reason : Instructing the client on how to leave the relationship is an important aspect of empowering the client; however, it is not the first action to take before assessing immediate risk and ensuring the client's safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Ecchymosis of the extremities is not a typical finding associated with common bile duct obstruction. It refers to bruising, which can have many causes unrelated to bile duct issues⁴.
Choice B reason : Straw-colored urine is usually a sign of well-hydrated and healthy individuals. In the case of common bile duct obstruction, the urine may actually become darker due to increased bilirubin levels⁴.
Choice C reason : Tenderness in the left upper abdomen is more commonly associated with issues related to the stomach, spleen, or pancreas, not the common bile duct⁴.
Choice D reason : Clay stools are a classic symptom of common bile duct obstruction. When bile flow is blocked, stools can lose their normal brown color and appear pale or clay-colored due to the absence of bilirubin⁴.
Correct Answer is C
Explanation
Choice A reason : While it is true that a healthcare provider may come to explain the situation, this response does not directly address the parent's concern about the reason for the nurse's action. It is important for the nurse to communicate clearly and directly about their responsibilities and the actions they have taken.
Choice B reason : This response indicates that the nurse has taken action by reporting to a supervisor, but it does not clarify the nurse's legal obligation to report suspected child abuse. It is essential for nurses to understand and communicate their role as mandated reporters to ensure transparency and trust in the healthcare setting¹.
Choice C reason : This is the most appropriate response because it directly addresses the parent's question and explains the nurse's legal responsibility. Nurses are mandated reporters and are legally required to report any suspicions of child abuse to protect the child's welfare. This response is clear, direct, and upholds the nurse's professional and legal obligations¹³.
Choice D reason : While contacting a supervisor may be part of the protocol, this response does not provide the parent with an explanation for the nurse's action. It is important for the nurse to explain their legal duty to report suspected child abuse, which is the primary reason for their action.
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