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?

A summary of the client’s feelings

The client’s significant other’s statement

A general description

Photographs

Answer and Explanation

The Correct Answer is D

A.   Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B.   The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D.   Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Chronic alcohol use is more likely to be associated with increased prothrombin time and partial thromboplastin levels due to impaired liver function.
B. Increased values of serum levels for liver function profile (such as AST, ALT, GGT) are common in individuals with chronic alcohol dependency.
C. Tolerance, where increasingly larger amounts of alcohol are needed to feel drunk, is a characteristic feature of alcohol dependency.
D. Periodic indigestion and negative occult blood in the stool may be indicative of alcohol- related gastrointestinal issues.
E. Memory lapses, especially blackouts or amnesia regarding events that occurred during drinking, are common in chronic alcohol use and dependency.

A. Tell the client to call Adult Protective Services if his son’s abuse continues. B. Verify the client’s report by determining if there is physical evidence of abuse. C. Refer the client to a program for victims of domestic violence. D. Assist the client in developing an emergency safety plan.

Correct Answer is D

Explanation

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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)

Correct Answer is ["B","C","D","E"]

Explanation

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?

Correct Answer is D

Explanation

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 client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

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?

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

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

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?

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

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?