A nurse is implementing crisis interventions for a client following an incidence of intimate partner abuse. 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. Help the client to identify effective past coping skills – While important, this is not the priority in a crisis situation.

B. Initiate precautions to safeguard the client from physical harm – Ensuring immediate safety is the top priority for a client in crisis. If the client is at risk of further harm, protective measures must be implemented.

C. Assist the client to identify available support systems – This is an important step but comes after ensuring safety.

D. Encourage the client to express feelings about the incident – Emotional support is important, but physical safety takes precedence in crisis situations.

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Correct Answer is C

Explanation

A. The non-dominant arm should be used when possible to minimize interference with daily activities.

B. The palmar side of the wrist is highly sensitive and should be avoided due to the risk of discomfort and nerve injury.

C. This is the correct answer. The nurse should select a site proximal to previous venipuncture sites to maintain vein integrity and avoid complications such as infiltration or phlebitis.

D. Using a larger gauge catheter increases the risk of phlebitis rather than preventing it.

A. Irritability B. Increased head circumference C. Hypotonicity D. Decreased auditory startle response

Correct Answer is A

Explanation

A. Irritability – This is the expected finding. Newborns exposed to cocaine in utero often exhibit irritability, hypertonia, tremors, and a high-pitched cry due to withdrawal symptoms and central nervous system excitability.

B. Increased head circumference – Cocaine use is associated with intrauterine growth restriction (IUGR), leading to smaller head circumferences rather than increased head size.

C. Hypotonicity – Cocaine-exposed newborns typically exhibit hypertonicity (increased muscle tone) rather than hypotonia.

D. Decreased auditory startle response – These newborns usually have an exaggerated Moro (startle) reflex rather than a decreased response.

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A nurse is implementing crisis interventions for a client following an incidence of intimate partner abuse. Which of the following is the priority action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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