The primary nursing intervention for a victim of child abuse is:

Correct Answer: C

Rationale: The correct answer is C: Ensure the safety of the victim. This is the primary nursing intervention for a victim of child abuse because ensuring the safety of the child is the most urgent and critical priority. By ensuring the safety of the victim, the nurse can prevent further harm and protect the child from ongoing abuse. Assessing the scope of the problem (choice A) and analyzing family dynamics (choice B) are important but secondary to ensuring the immediate safety of the child. Teaching coping skills (choice D) can be beneficial, but it is not the primary intervention needed to address the immediate safety concerns of a child abuse victim.

Correct Answer: D

Rationale: The correct answer is D: Administering Librium as ordered. This is the priority because Librium is a medication prescribed for specific therapeutic reasons, such as managing withdrawal symptoms or anxiety. Administering it as ordered ensures the client's safety and well-being. Monitoring vital signs (A) is important but not the priority over administering necessary medication. Providing a quiet, dim room (B) and encouraging fluids and nutrition (C) are important for comfort and health but do not address immediate medical needs like medication administration.

Correct Answer: C

Rationale: The correct answer is C because approaching the nurse and talking out her feelings is a proactive and healthy intervention. By discussing her emotions with a healthcare professional, the client can receive support and guidance to address the underlying causes of her urge to starve. This intervention promotes open communication and helps the client develop coping strategies to manage her feelings in a constructive manner. Option A is incorrect as allowing the client to starve can lead to serious health consequences and does not address the root of the issue. Option B may provide temporary distraction but does not address the emotional aspect of the urge to starve. Option D involves seeking external validation rather than addressing the client's emotional needs directly.

Correct Answer: A

Rationale: The correct answer is A: Avoid taking CNS depressants like alcohol. Valium is a central nervous system (CNS) depressant, so combining it with other CNS depressants like alcohol can lead to dangerous levels of sedation, respiratory depression, and even overdose. It is crucial to educate clients to avoid alcohol while taking Valium to prevent these serious complications. Explanation for incorrect choices: B: There are no restrictions in activities - This is incorrect because clients taking Valium should be advised to avoid activities that require mental alertness or coordination due to the sedative effects of the medication. C: Limit fluid intake - This is incorrect as there is no specific need to limit fluid intake while taking Valium unless advised by a healthcare provider for other medical reasons. D: Any beverage like coffee may be taken - This is incorrect as caffeine in beverages like coffee can potentially interact with Valium and affect its effectiveness, so it is important to provide guidance on caffeine intake while on Valium.

Correct Answer: A

Rationale: The correct answer is A: Education and work history. The nurse would identify this as least significant in contributing to the client's sexual difficulty because education and work history do not directly impact sexual arousal or fear of infidelity in a marriage. Rationale: 1. B: Medication used - Medications can have side effects that affect sexual arousal and libido. 2. C: Physical health status - Physical health can impact sexual function and overall well-being. 3. D: Quality of spousal relationship - Relationship dynamics can significantly influence sexual arousal and fear of infidelity. In summary, the client's education and work history are less likely to directly affect her sexual difficulties compared to medication, physical health, and the quality of her spousal relationship.