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 B

Explanation

Choice A reason : Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) which can be detrimental to patients with congestive heart failure (CHF). NSAIDs can lead to sodium and fluid retention, exacerbating CHF symptoms and potentially leading to a worsening of the condition⁶⁷. Therefore, it is not recommended for managing discomfort in CHF patients.

Choice B reason : Slowing down if feeling tired after exercising is a prudent measure for anyone, especially for CHF patients. It indicates the patient is listening to their body and respecting its limits, which is essential in managing CHF. Overexertion can strain an already compromised heart, so moderation and careful monitoring of physical activity are key¹².

Choice C reason : The recommended daily sodium intake for heart failure patients is generally less than 2,000 mg¹⁶¹⁷¹⁸. A limit of 4 grams per day is significantly higher than the recommended amount and could lead to fluid retention and worsening of heart failure symptoms. Therefore, this statement does not reflect effective teaching.

Choice D reason : Diuretics are often prescribed to CHF patients to manage fluid retention. However, taking diuretics before sleep can lead to nocturia, disrupting sleep due to the need to urinate at night. It is generally recommended to take diuretics earlier in the day, with the last dose no later than 4 p.m., to minimize nighttime disruptions¹³¹⁴. Drinking fluids during the day without restriction can also contribute to fluid overload, which is counterproductive in CHF management.

A. Pupillary changes B. Disorientation C. Headache D. Slurred speech E. Neck pain and stiffness

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason : Pupillary changes, such as unequal pupil sizes or a sluggish reaction to light, can be a sign of increased ICP. The cranial nerves that control the pupils may be compressed due to the swelling of the brain, leading to these changes¹.

Choice B reason : Disorientation, including confusion and changes in alertness, can occur with increased ICP as the pressure affects the brain's ability to process information and maintain consciousness².

Choice C reason : Headache is a common symptom of increased ICP. It can be severe and persistent due to the pressure exerted on the meninges and blood vessels within the brain³.

Choice D reason : Slurred speech may result from increased ICP if the areas of the brain responsible for speech and muscle control are affected by the pressure².

Choice E reason : Neck pain and stiffness, particularly when trying to flex the neck forward, can be indicative of meningeal irritation, which can be associated with increased ICP⁴.

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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

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Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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