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?
Ask the client to describe the history of the injuries.
Invite a colleague to document during the interview.
Close the examination room door for privacy.
Request hospital security to come to the department.
The Correct Answer is C
A. While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B. Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D. Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Self-absorption refers to excessive focus on oneself, which is not the primary issue described in this scenario.
B. Self-actualization involves realizing one's potential and may not be the immediate concern for a person dealing with trauma.
C. Self-control relates to managing one's impulses and behavior, which may not be the primary issue in this context.
D. Self-esteem is the concept most closely related to feelings of self-blame and is a common struggle for individuals who have experienced trauma. The client is grappling with self-worth and blaming herself for not taking precautions.
Correct Answer is A
Explanation
A. Disulfiram should be taken each morning, and it is recommended to start it 48 hours after the last drink of alcohol to prevent a severe reaction. This helps establish a clear association between the medication and alcohol avoidance.
B. While taking disulfiram with water is generally advisable, the crucial aspect is the timing and the initial 48-hour abstinence period.
C. Taking the medication at bedtime or limiting alcohol to one ounce daily does not address the specific timing requirement for disulfiram initiation.
D. Beginning the medication immediately and taking it daily, regardless of alcohol consumption, may not establish the necessary 48-hour alcohol-free period before starting disulfiram.
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