A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment?

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Question 1 of 5

A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment?

Correct Answer: A

Rationale: The correct answer is A: Danger Assessment Screen. This tool is specifically designed to assess the risk of lethality in individuals who have experienced abuse. It includes questions related to the severity and frequency of abuse, as well as other risk factors such as access to weapons and history of threats. It helps identify clients at high risk of harm or death. B: Abuse Assessment Screen is a screening tool to identify abuse but does not specifically focus on lethality risk. C: Burgess-Partner Abuse Scale is a measure of the frequency and severity of intimate partner violence, but it does not assess lethality risk. D: Beck Depression Inventory is a tool to assess the severity of depression and is not designed to evaluate the risk of harm or death in abuse survivors.

Question 2 of 5

Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

Correct Answer: B

Rationale: The correct answer is B because it highlights the importance of checking for congruence between verbal and nonverbal communication to validate responses. This demonstrates an understanding that nonverbal cues can provide additional insights into a patient's true feelings or thoughts. Choice A is incorrect as it simply states a general observation without emphasizing the significance of nonverbal cues. Choice C is incorrect because assuming a patient's emotions based solely on body posture is not accurate or reliable. Choice D is incorrect as it undervalues the importance of nonverbal communication in understanding the complete message being conveyed.

Question 3 of 5

Which statement made by the primary caregiver of a patient diagnosed with dementia demonstrates accurate understanding of providing the patient with a safe environment?

Correct Answer: C

Rationale: The correct answer is C: "We've installed locks on all the outside doors." This statement shows an understanding of the need to prevent the patient with dementia from wandering off and getting lost or injured. Installing locks on outside doors helps to ensure the patient's safety by limiting their ability to leave the house unsupervised. This measure is crucial in providing a secure environment for someone with dementia. Explanation: A: The statement about the local police knowing the patient has wandered off before does not address the immediate need to prevent wandering and ensure safety. B: Keeping the noise level low in the house may be helpful for a patient with dementia, but it does not directly address the safety concern of wandering. D: Attaching the telephone number to the patient's shirt pocket is a good safety measure, but it does not address the primary concern of preventing the patient from wandering off.

Question 4 of 5

You are caring for Ellie, age 91, whose provider has written a 'DNR-CCO' order. Which nursing action would be appropriate if Ellie were to go into cardiac arrest?

Correct Answer: C

Rationale: The correct answer is C. Administer prescribed medication morphine for pain control. In this scenario with a 'DNR-CCO' order, the focus is on comfort care rather than resuscitation. Administering morphine for pain control aligns with the patient's wishes and provides comfort during a potentially distressing event. Calling for the code team (A) and initiating CPR (D) would go against the DNR order. Notifying the attending physician and family (B) is important but not the immediate nursing action needed during a cardiac arrest in this case.

Question 5 of 5

What is the term for clients' movement between treatment settings?

Correct Answer: D

Rationale: The correct answer is D: transition of care. Transition of care refers to clients moving between treatment settings, ensuring continuity and coordination of care. Rehospitalization (A) specifically refers to clients being admitted back to the hospital. Adverse event (B) refers to harm resulting from medical care. Readmission (C) is similar to rehospitalization, specifically indicating clients being admitted back to a hospital after a previous discharge. Transition of care (D) is the most appropriate term as it encompasses the movement of clients between various healthcare settings beyond just hospitals.

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