An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

Tell the client to call Adult Protective Services if his son’s abuse continues.

Verify the client’s report by determining if there is physical evidence of abuse.

Refer the client to a program for victims of domestic violence.

Assist the client in developing an emergency safety plan.

Answer and Explanation

The Correct Answer is D

A.   Telling the client to call Adult Protective Services is a valid intervention, but immediate safety planning is crucial.
B.   Verifying the client's report by determining physical evidence is important but may not be the most immediate and practical intervention.
C. Referring the client to a program for victims of domestic violence is a valuable option, but immediate safety planning should take precedence.
D.   Assisting the client in developing an emergency safety plan is the most important intervention to ensure the client's safety in the present situation.

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Correct Answer is D

Explanation

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

A. Support the client to list small behavioral changes needed. B. Explain the specific skills needed to prevent a relapse. C. Provide teaching on the symptoms of substance use dependence. D. Advise the client to reschedule until committing to recovery.

Correct Answer is A

Explanation

A. Supporting the client to list small behavioral changes is a person-centered and achievable approach to promote progress.
B. Explaining specific skills needed to prevent a relapse may be overwhelming at this early stage.
C. Providing teaching on symptoms of substance use dependence may not be the most immediate and practical response to the client's expressed desire for positive change.
D. Advising the client to reschedule until committing to recovery is not supportive and may discourage the client's motivation for positive change.

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An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct Answer is D

Explanation

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

Correct Answer is A

Explanation

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?

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A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

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The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?