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 C

Explanation

A. While allowing freedom in choosing seats may be acceptable, in this scenario, encouraging a more cohesive and interactive group setting is beneficial.
B. Suggesting that they all sit together to increase interaction is a reasonable approach to enhance group dynamics.
C. Asking the adolescent sitting on the couch to join the group at the table promotes inclusivity and equal participation.
D. Determining which adolescents would like to participate may not be necessary; encouraging all to participate fosters a collaborative atmosphere.

A. Use relaxation techniques to reduce excessive anxiety. B. Avoid alcohol and other sedatives while taking the medication. C. Move slowly from a sitting position to a standing position. D. Stop taking the medication if the intended effect is not immediate.

Correct Answer is D

Explanation

A. Using relaxation techniques is a positive and appropriate strategy for managing anxiety.
B. Avoiding alcohol and other sedatives is essential as they can potentiate the sedative effects of lorazepam.
C. Moving slowly from a sitting to a standing position is important to minimize orthostatic hypotension, a potential side effect of lorazepam.
D. Stopping the medication if the intended effect is not immediate is not appropriate guidance.
Lorazepam, like many benzodiazepines, may take some time to achieve its full therapeutic effect. Abrupt discontinuation can lead to withdrawal symptoms and should be done under the guidance of a healthcare provider.

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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

The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

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?