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. Encouraging daily weigh-ins may exacerbate anxiety and fixation on weight, which is not therapeutic.
B. Exercise and recreation recommendations should align with the treatment plan and be individualized; morning activities are not universally indicated.
C. Allowing the client to select an arts and crafts activity provides a positive outlet for expression and engagement in non-food-related activities.
D. Putting the client in charge of choosing snacks for the unit may not be appropriate, as it could contribute to unhealthy food-related behaviors.

A. Tell the client to discuss his ideas with others when his thoughts are more clear. B. Teach the client to slow down and focus on the topic by listening to his words. C. Ask the client to repeat his comments. D. Confront the client when he talks rapidly.

Correct Answer is B

Explanation

A. Telling the client to discuss his ideas when his thoughts are more clear may not be effective as it does not provide immediate guidance on improving communication.
B. Teaching the client to slow down and focus on the topic by listening to his words is a therapeutic intervention to address tangential speech and promote effective communication.
C. Asking the client to repeat his comments may not directly address the issue of tangential speech and may not be as therapeutic as providing guidance on communication techniques.
D. Confronting the client when he talks rapidly may be perceived as confrontational and may not be the most therapeutic approach to address tangential speech.

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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

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

Correct Answer is C

Explanation

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

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?

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