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 B

Explanation

A. Rearrange furniture to clear walkways – While important for fall prevention, it does not directly address medication safety.

B. Use container lids of different shapes to indicate times of administration – Correct. Using distinct tactile markers helps clients with vision loss distinguish medications and adhere to their regimen.

C. Cover appliance cords with throw rugs – Incorrect. Throw rugs are a tripping hazard and should be removed, not used to cover cords.

D. Visit the client once per month to assess medication usage – Monthly visits may not be sufficient for ensuring medication adherence and safety.

A. Place the client in Trendelenburg position during the procedure. B. Instruct the client to maintain a full bladder for the procedure. C. Administer a tocolytic 30 min before the procedure. D. Monitor the fetal heart rate throughout the procedure.

Correct Answer is D

Explanation

A. Place the client in Trendelenburg position during the procedure – Incorrect, as amniocentesis is typically performed with the client in a supine position.

B. Instruct the client to maintain a full bladder for the procedure – This is required for an early pregnancy amniocentesis (before 20 weeks), but for later procedures, the bladder should be empty.

C. Administer a tocolytic 30 min before the procedure – Not routinely necessary unless the client is at risk for preterm labor.

D. Monitor the fetal heart rate throughout the procedure – Correct, as amniocentesis carries a risk of fetal distress, and continuous monitoring ensures immediate detection of complications.

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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

A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day. Which of the following actions should the nurse include in the plan?

Correct Answer is B

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Correct Answer is D

Explanation

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