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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administering disulfiram is not the priority in the immediate care of a client with a closed head injury and elevated blood alcohol level. The focus should be on ensuring the client's safety and preventing complications related to the head injury.
B. Placing the client in a side-lying position with the head of the bed elevated is crucial to prevent aspiration and maintain airway patency in a client who is difficult to arouse due to alcohol intoxication.
C. Giving lorazepam for signs of withdrawal may be necessary but does not address the immediate risk of aspiration in a client with altered consciousness.
D. Providing thiamine and folate supplements is important for clients with alcohol use disorders, but the priority in this scenario is airway protection and preventing complications related to the head injury.
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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