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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Isopropyl alcohol can damage the hearing aid.
B. Battery life varies, and replacement should be based on performance rather than a set timeframe.
C. This is the correct answer. Disconnecting the battery when not in use preserves battery life.
D. Cotton swabs can push wax deeper into the ear canal.
Correct Answer is D
Explanation
A. Emptying an indwelling urinary catheter bag with clean gloves is appropriate and does not require intervention.
B. Performing a simple dressing change on a client’s foot is within the AP's scope of practice if the dressing is not complex or sterile.
C. Providing postmortem care is within the AP's role and does not require intervention unless specific contraindications exist.
D. Clostridium difficile (C. diff) spores are resistant to alcohol-based hand rubs. The AP must use soap and water for hand hygiene to effectively remove spores. This is an infection control breach that requires immediate intervention.
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