A nurse is working with a client who is a survivor of violence on developing a safety plan. Which of the following would the nurse address first?

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Question 1 of 5

A nurse is working with a client who is a survivor of violence on developing a safety plan. Which of the following would the nurse address first?

Correct Answer: B

Rationale: The correct answer is B, recognizing the signs of danger, as it is crucial to be able to identify potential threats before devising an escape plan or identifying safe places. By recognizing signs of danger, the client can proactively assess risky situations and take necessary precautions. This step is vital in ensuring the client's safety and preventing harm. Option A, devising an escape route, would be ineffective if the client cannot recognize the signs of danger to know when to use the route. Option C, identifying a safe place to hide, is not as effective as recognizing signs of danger since hiding may not always be a viable solution. Option D, identifying a signal to indicate it is safe to leave, would not be effective if the client cannot accurately assess when it is safe to leave. Recognizing signs of danger is the foundational step in creating a comprehensive safety plan.

Question 2 of 5

When should a nurse be most alert to the possibility of communication errors resulting in harm to the patient?

Correct Answer: A

Rationale: The correct answer is A: Change of shift report. During this time, vital patient information is transferred between nurses, making it crucial to be alert to communication errors. Patient safety relies on accurate and clear communication. Other choices (B, C, D) involve important communication opportunities, but the handover of information during shift change is when critical details can be missed or misunderstood, leading to potential harm. It is essential for nurses to focus on effective communication during this transition to ensure continuity of care and patient safety.

Question 3 of 5

When considering the pathophysiology responsible for both delirium and dementia, which intervention is appropriate for delirium specifically?

Correct Answer: B

Rationale: The correct answer is B: Monitor neurological status on an ongoing basis. Delirium is characterized by acute changes in cognition and attention, necessitating continuous monitoring of neurological status to detect any fluctuations or worsening. This allows for prompt intervention and management to prevent complications. A: Assisting with basic needs is important but not specific to delirium management. C: Placing an identification bracelet does not directly address the cognitive changes seen in delirium. D: Giving simple directions is helpful, but monitoring neurological status is more crucial for managing delirium.

Question 4 of 5

A 73-year-old man was diagnosed with a serious mental illness at age 20. Subsequently, he was frequently hospitalized. Two years ago, he was transferred to a group home. When considering the effects of institutionalization, which behavior demonstrates adaptation to the new environment?

Correct Answer: C

Rationale: The correct answer is C: Makes himself lunch when he is hungry. This behavior demonstrates adaptation to the new environment as it shows independence and self-care skills. Choosing to prepare a meal when hungry indicates the individual is adjusting to living in the group home by taking care of his basic needs. Options A, B, and D are not necessarily indicative of adaptation to the new environment as they could be influenced by external factors or personal preferences without necessarily reflecting effective adjustment to the group home setting.

Question 5 of 5

Graciela is a sixty-three-year-old woman who recently became the primary caregiver for her husband who had a stroke. She tells her husband's nurse that she has been feeling lonely and sad lately and that none of her friends seem to understand what she is going through. What community resource would best benefit Graciela?

Correct Answer: D

Rationale: The correct answer is D: a support group for adult caregivers. Graciela is experiencing feelings of loneliness and sadness due to her new role as a caregiver for her husband. A support group for adult caregivers would provide her with a community of individuals who are going through similar experiences, offering emotional support, understanding, and coping strategies. This resource can help Graciela feel less isolated and more supported in her caregiving journey. Choice A (the local food pantry) does not address Graciela's emotional needs and is not directly related to her situation as a caregiver. Choice B (a rideshare service) is focused on transportation to church and does not address Graciela's feelings of loneliness and sadness. Choice C (a social worker for subsidized housing) does not specifically address Graciela's emotional well-being and may not provide the necessary support for her current situation as a caregiver.

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