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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason : Implementing seizure precautions is necessary for a child with bacterial meningitis due to the increased risk of seizures associated with the condition.

Choice B reason : Placing the client in a semi-Fowler's position can help reduce intracranial pressure and facilitate breathing, which is beneficial for a child with meningitis.

Choice C reason : Admitting the client to a private room is important to prevent the spread of infection and provide a quiet environment to reduce the risk of seizures and other complications.

Choice D reason : Measuring head circumference every shift is not typically necessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants whose skull bones have not yet fused.

A. Have the client floss 4 times daily. B. Have the client swish with commercial mouthwash before therapy. C. Tell the client to expect dark stools following chemotherapy. D. Administer an antiemetic prior to the procedure.

Correct Answer is D

Explanation

Choice A reason : Having the client floss 4 times daily is not typically recommended during chemotherapy because their gums may be more prone to bleeding due to a decrease in platelets, which is a common side effect of chemotherapy¹. Instead, gentle oral care is advised to prevent damage to the oral mucosa.

Choice B reason : Having the client swish with commercial mouthwash before therapy is not generally recommended because many commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes and may exacerbate chemotherapy-induced mucositis¹. Instead, a saline rinse or a prescribed mouthwash without alcohol may be used to help manage oral hygiene during chemotherapy.

Choice C reason : Telling the client to expect dark stools following chemotherapy could be misleading. While some chemotherapy drugs can cause changes in stool color, dark stools can also indicate gastrointestinal bleeding, which requires immediate medical attention¹. Therefore, patients should be instructed to report any significant changes in stool color to their healthcare provider.

Choice D reason : Administering an antiemetic prior to the procedure is a standard practice to prevent nausea and vomiting associated with chemotherapy¹. Antiemetics are medications that can help control these common side effects, improving the patient's comfort and ability to tolerate the treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Correct Answer is D

Explanation

A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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