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 : 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.

A. Long-term treatment of obsessive-compulsive disorder. B. Short-term treatment of panic attacks. C. Long-term treatment of agoraphobia. D. Short-term treatment of depression.

Correct Answer is B

Explanation

Choice A reason : Benzodiazepines are not typically used for the long-term treatment of obsessive-compulsive disorder due to the risk of dependence and because other medications, such as SSRIs, are more effective for long-term management⁵.

Choice B reason : Benzodiazepines are effective for the short-term management of panic attacks due to their rapid onset of action, which can quickly alleviate acute symptoms of anxiety and panic⁵⁹.

Choice C reason : Long-term treatment of agoraphobia generally involves psychotherapy and SSRIs or SNRIs rather than benzodiazepines, which can lead to dependence and are not recommended for long-term use⁵.

Choice D reason : Benzodiazepines are not the first-line treatment for depression and are generally not used for this purpose. Antidepressants and psychotherapy are the standard treatments for depression⁵.

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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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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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