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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Related Questions
Correct Answer is B
Explanation
Choice A reason : While it is important to assure the client, the nurse must first verify that there is a formal DNR order in place to legally honor the client's wishes¹².
Choice B reason : Checking for a DNR order in the medical record is the correct action to ensure that the client's wishes regarding resuscitation are documented and will be followed by all healthcare providers¹².
Choice C reason : Asking about a healthcare proxy is important, but it is secondary to confirming that the client's wishes are documented in the medical record through a DNR order or advance directives¹².
Choice D reason : Verifying a signed copy of the advance directives is crucial, but the immediate step is to check for a DNR order, which is specifically related to the client's request not to be resuscitated¹².
Correct Answer is A
Explanation
Choice A reason : Individuals with OCD often engage in compulsive behaviors, such as picking up after others, to make their environment feel more controlled or tolerable. This behavior is a response to the anxiety produced by their obsessions, which in this case, could be related to cleanliness or order¹. By controlling their immediate environment, they may feel a temporary relief from their anxiety, even though this relief is often short-lived and the compulsion becomes a repetitive cycle².
Choice B reason : Changing tasks is not typically the goal of compulsive behaviors in OCD. These behaviors are usually very specific and are performed to manage the anxiety associated with particular obsessions. While the individual might switch from one compulsive behavior to another, it is not done with the intention of task variation but rather as a response to shifting obsessive thoughts¹.
Choice C reason : Compulsive behaviors in OCD are not aimed at increasing social interaction. In fact, these behaviors can often interfere with social activities and relationships, as they can be time-consuming and may make the individual feel embarrassed or ashamed, leading to social isolation².
Choice D reason : Compulsive behaviors can sometimes be a way for individuals with OCD to exert control over other behaviors or thoughts. However, the primary function of these behaviors is to manage the anxiety associated with obsessions, not necessarily to control other unrelated behaviors¹.
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