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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer the medication subcutaneously – Diazepam should be given orally or intravenously in severe cases, not subcutaneously.
B. Initiate seizure precautions – This is the correct answer. Alcohol withdrawal can lead to seizures due to central nervous system hyperactivity. Diazepam, a benzodiazepine, is used to prevent seizures and manage withdrawal symptoms.
C. Administer the medication with an antacid – There is no need to administer diazepam with an antacid; doing so can interfere with absorption.
D. Initiate contact precautions – Alcohol withdrawal is not an infectious condition, so contact precautions are unnecessary.
Correct Answer is A
Explanation
A. Respite care – This is the correct answer. Respite care provides temporary relief to caregivers by offering short-term professional care for the client, allowing the caregiver to rest and prevent burnout.
B. Skilled nursing facility – A skilled nursing facility is for long-term or intensive medical care needs, not temporary relief for a caregiver.
C. Rehabilitation services – Rehabilitation focuses on the client’s recovery, not the caregiver’s need for rest.
D. Assisted living – Assisted living is for clients needing ongoing assistance with daily activities, not temporary relief for a caregiver.
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