A nurse is reinforcing teaching about a safety plan for a client who reports partner violence. Which of the following instructions should the nurse include?

"Call a shelter in another county."

"Leave your partner immediately."

"Keep a packed bag by your front door."

"Rehearse your escape route."

Answer and Explanation

The Correct Answer is D

The nurse should include the instruction to "Rehearse your escape route" in the safety plan for a client who reports partner violence. A safety plan is a personalized and practical plan on how to remain safe in an abusive relationship while preparing to leave when the timing is right and safe to do so . Rehearsing an escape route can help the client be prepared and know what to do in case they need to leave quickly.

Option a is incorrect because calling a shelter in another county may not be the most practical or eﬀective option for the client.

Option b is incorrect because leaving an abusive partner immediately may not always be the safest option for the client.

Option c is incorrect because keeping a packed bag by the front door may not be the most practical or eﬀective option for the client.

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Correct Answer is D

Explanation

The nurse should expect to find hyperkalemia in the medical record of a client who has sustained a full- thickness burn and is in the emergent phase of the burn. This is due to the release of potassium from damaged cells into the bloodstream.

a) Hypernatremia is not a common finding in the emergent phase of a burn.

b) Hypercalcemia is not a common finding in the emergent phase of a burn.

c) Hypermagnesemia is not a common finding in the emergent phase of a burn.

A. Encourage the client to gain 2.3 kg (5 lb) per week. B. Monitor the client for 15 min after meals C. Weigh the client each morning after voiding D. Reinforce teaching about healthy eating during meals

Correct Answer is C

Explanation

Answer: C. Weigh the client each morning after voiding

Rationale:

A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.

B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.

C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.

D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.

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A nurse is reinforcing teaching about a safety plan for a client who reports partner violence. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Correct Answer is C

Explanation

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