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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
Correct Answer is C
Explanation
A. Turning the client every 4 hours is too infrequent for a postoperative patient. The client should be turned at least every 2 hours to prevent complications such as pressure injuries.
B. An air mattress may help prevent pressure ulcers, but it does not specifically address postoperative care for an amputation.
C. Using an overbed trapeze allows the client to move independently, reducing strain on the residual limb and promoting mobility while preventing pressure injuries.
D. The bandage should be rewrapped every 4 to 6 hours in a figure-eight pattern, not every 8 hours in a circular pattern, to promote proper shaping of the residual limb and prevent circulation issues.
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