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 D
Explanation
A. Beneficence – This principle refers to doing good for the client, such as providing effective care and promoting well-being. While the nurse is educating the client, this action is more about truthfulness than actively promoting well-being.
B. Fidelity – Fidelity refers to maintaining trust and keeping commitments to the client. While honesty builds trust, fidelity is more about keeping promises rather than providing truthful information.
C. Autonomy – Autonomy means respecting a client’s right to make decisions about their care. While education supports informed decision-making, the nurse’s focus in this scenario is on honesty rather than respecting autonomy.
D. Veracity – Veracity refers to truthfulness and honesty in communication. The nurse is providing accurate information about the side effects of transcranial magnetic stimulation, ensuring that the client has correct expectations.
Correct Answer is D
Explanation
A. Chvostek’s sign is associated with hypocalcemia, not lithium toxicity.
B. Lithium does not increase potassium levels; it may cause mild hyponatremia.
C. Lithium is more commonly associated with diarrhea, not constipation.
D. Lithium can cause nephrogenic diabetes insipidus, leading to increased urinary output.
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