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 C

Explanation

Choice A reason : White beans do not have a significant interaction with warfarin. They are a good source of protein and fiber and can be included in the diet unless otherwise contraindicated.

Choice B reason : Cantaloupe does not interact significantly with warfarin and can be consumed as part of a balanced diet. It is rich in vitamins and hydration.

Choice C reason : Cabbage contains vitamin K, which can interfere with the effectiveness of warfarin. Vitamin K is essential for blood clotting, and warfarin works by inhibiting the effects of this vitamin. Therefore, patients on warfarin are advised to maintain a consistent intake of vitamin K and avoid sudden increases in foods high in this nutrient.

Choice D reason : Green beans have a moderate amount of vitamin K but are not typically restricted for patients on warfarin. It is important for patients to maintain a consistent intake of vitamin K; thus, they should not make significant changes to their diet without consulting their healthcare provider.

A. Heat intolerance B. Facial edema C. Tachycardia D. Diarrhea

Correct Answer is B

Explanation

Choice A reason : Heat intolerance is not a symptom associated with myxedema coma. Instead, patients with myxedema coma typically present with cold intolerance due to decreased metabolic rate and reduced heat production as a result of hypothyroidism¹.

Choice B reason : Facial edema, particularly around the eyes, is a characteristic finding in myxedema coma. This condition results from severe hypothyroidism, which can cause mucopolysaccharide deposition in the skin, leading to non-pitting edema¹.

Choice C reason : Tachycardia is not expected in myxedema coma; rather, bradycardia is more common due to the reduced metabolic demands of the body in the hypothyroid state¹.

Choice D reason : Diarrhea is not typically a symptom of myxedema coma. Patients are more likely to experience constipation due to slowed gastrointestinal motility in the context of hypothyroidism¹.

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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 in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?

Correct Answer is C

Explanation

A nurse is assessing a client who has myxedema coma. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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