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. Establish a new routine for the child to follow while in the facility. This is incorrect because preschoolers find comfort in familiar routines. Maintaining their usual routines as much as possible helps reduce anxiety.
B. Use medical terminology when discussing procedures with the child. This is incorrect because preschoolers have a limited understanding of medical terms. Using simple, age-appropriate language helps them better comprehend what is happening.
C. Encourage the child to play with toys such as a pounding board. This is correct because preschoolers benefit from play to express emotions and relieve stress. Toys like a pounding board allow them to release frustration in a safe and developmentally appropriate way.
D. Perform the morning assessments when the parent is not in the room. This is incorrect because having a parent present provides comfort and security, which can help the child remain calm during assessments.
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.
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