A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first?

Empower the client to feel that he is in charge of his life.

Find the client a temporary shelter where he can feel safe.

Determine if the client has thoughts about self-harm.

Review the client's available social support system

Answer and Explanation

The Correct Answer is C

Choice A reason

Empowering the client to feel in charge of his life is essential for promoting coping and a sense of control over the situation. However, it may not be the first priority when the client's safety is in question.

Choice B reason:

Finding the client, a temporary shelter where he can feel safe is important for meeting the client's immediate physical needs, but it can be addressed after ensuring his emotional well-being and safety.

Choice C reason

The client's partner has died in a traumatic event, and the loss of both a loved one and their home can be emotionally overwhelming and distressing. The nurse's first priority should be to assess the client's safety and well-being, especially considering the potential for thoughts of self-harm or suicide.

Assessing for thoughts of self-harm is critical because the client may be experiencing intense grief, guilt, or hopelessness, which can increase the risk of self-harm or suicidal ideation. Identifying these thoughts early allows the nurse to initiate appropriate interventions, provide emotional support, and involve mental health professionals if necessary.

Choice D reason

Reviewing the client's available social support system is significant for addressing the client's emotional needs and establishing a support network. However, ensuring the client's safety takes precedence over this action.

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Correct Answer is B

Explanation

A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.

B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.

C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.

D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.

A. Arch B. Drooling C. Fever D. Steatorrhea

Correct Answer is C

Explanation

Choice A reason:

Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.

Choice B reason:

Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.

Choice C reason:

Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.

Choice D reason:

Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.

Choice E reason:

Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.

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A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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