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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Hypertension is not a typical finding of hypocalcemia. Instead, hypocalcemia can cause hypotension due to decreased myocardial contractility.
B. Muscle twitching is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to twitching, tetany, and spasms.
C. A bounding pulse is not associated with hypocalcemia. Instead, hypocalcemia can cause weak, thready pulses due to decreased cardiac output.
D. Increased urine output is not a direct symptom of hypocalcemia. However, hypercalcemia can lead to polyuria due to its effect on the kidneys.

A. Remind the AP about maintaining client confidentiality. B. Notify the client of the breach of confidentiality. C. Notify the ethics committee of the breach of confidentiality. D. File an incident report with the risk management department.

Correct Answer is A

Explanation

A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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