A nurse is implementing crisis intervention for a client following an incident of partner violence. Which of the following is the priority action for the nurse to take?
Help the client to identify effective past coping skills.
Initiate precautions to safeguard the client from physical harm.
Assist the client to identify available support systems.
Encourage the client to express feelings about the incident.
The Correct Answer is B
A. Identifying past coping skills is important but is not the priority in a crisis situation where the client's safety is at risk.
B. Ensuring the client’s immediate safety is the priority because they may still be in danger from the abusive partner. Crisis intervention focuses first on protecting the client from further harm.
C. Identifying support systems is beneficial for long-term recovery but does not take precedence over ensuring the client’s immediate safety.
D. Encouraging expression of feelings is therapeutic, but the priority is to remove the client from immediate harm before addressing emotional needs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm. This is incorrect because the arteriovenous shunt is in the lower forearm, not the upper arm where blood pressure is measured. The right arm can still be used.
B. A client who had a right hemisphere stroke. This is incorrect because a stroke does not necessarily contraindicate blood pressure measurement on the affected side unless there are complications such as edema or weakness.
C. A client who has a right peripherally inserted central catheter. This is correct because taking a blood pressure on the same side as a peripherally inserted central catheter (PICC) can cause pressure that may damage the catheter or affect its function. The left arm should be used instead.
D. A client who had blood drawn from the right antecubital area 1 hr ago. This is incorrect because drawing blood from an arm does not contraindicate blood pressure measurement in that arm after a short period.
Correct Answer is B
Explanation
A. Shaking insulin vials can cause bubbles and denature the insulin, especially NPH, which should be gently rolled between the hands to mix. Vigorous shaking can reduce effectiveness and increase the risk of inaccurate dosing.
B. Once regular and NPH insulin are drawn into the same syringe, the mixture should be administered promptly, ideally within 5 minutes, to maintain potency and prevent clumping. Delays can alter absorption and efficacy of the insulin.
C. The correct technique is to withdraw regular insulin first and then NPH, not the other way around. Drawing NPH first could contaminate the regular insulin vial with NPH, affecting rapid-acting insulin activity.
D. Air should be injected into each vial to equalize pressure before withdrawing the insulin, but the sequence should be air into NPH first, then air into regular insulin, to avoid contamination. Incorrect sequencing can introduce NPH into the regular insulin vial.
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