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. Use clean technique for invasive procedures. – Incorrect. Sterile technique, not clean technique, is required to prevent infection in neutropenic clients.

B. Allow healthy children to visit. – Incorrect. Clients with neutropenia should avoid exposure to children due to the risk of infections.

C. Monitor the client's temperature every 4 hr. – Correct. Fever can indicate infection, which is life-threatening for neutropenic clients. Early detection is crucial.

D. Make sure the client's room is cleaned every 2 days. – Incorrect. The room should be cleaned daily to reduce infection risk.

A. Shake both insulin vials for 2 min before withdrawing the doses. B. Administer the mixture within 5 min of preparing it. C. Withdraw the NPH insulin before the regular insulin. D. Inject air into the regular insulin vial before injecting air into the NPH vial.

Correct Answer is B

Explanation

A. Insulin vials should not be shaken because this can create air bubbles, leading to inaccurate dosing. Instead, NPH insulin should be gently rolled between the palms to evenly mix the suspension. Regular insulin does not require mixing.

B. Once regular and NPH insulin are mixed, they should be administered promptly to maintain their stability and effectiveness. Delaying administration may alter insulin absorption, leading to unpredictable glucose control.

C. Regular insulin should be drawn up before NPH insulin to prevent contaminating the clear regular insulin with the cloudy NPH insulin. The correct order is to inject air into the NPH vial first (without withdrawing insulin), then inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.

D. The correct technique is to first inject air into the NPH vial, then inject air into the regular insulin vial. This prevents contamination and maintains sterility. However, when withdrawing insulin, regular insulin is drawn first to prevent mixing of NPH insulin into the regular insulin vial.

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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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