Correct Answer: B

Rationale: The correct answer is B: Initiate precautions to safeguard the client from physical harm. This is the priority action because ensuring the client's safety is paramount in crisis intervention. By taking precautions to safeguard the client from physical harm, the nurse addresses the immediate risk of harm and creates a secure environment for further interventions.


Choice A: Helping the client identify effective coping skills is important, but physical safety takes precedence in a crisis situation.

Choice C: Identifying support systems is valuable, but ensuring physical safety is more urgent.

Choice D: Encouraging the client to express feelings is essential, but safety concerns must be addressed first in cases of partner violence.

In summary, the nurse should prioritize safeguarding the client from physical harm to establish a foundation for further support and interventions.

Correct Answer: C

Rationale: The correct action for the nurse to take in this scenario is to cover the wound with a saline-soaked dressing (
Choice
C). This is based on the principle of protecting the exposed tissue from contamination and preventing further complications such as infection. By covering the wound with a saline-soaked dressing, the nurse can create a moist environment that can help promote healing and reduce the risk of infection. Reinserting the protruding intestinal tissue (
Choice
A) should not be done by the nurse, as this is a medical intervention that should be performed by a healthcare provider. Placing the client in Trendelenburg position (
Choice
B) is not necessary and may not address the primary concern of wound separation. Monitoring vital signs every 30 minutes (
Choice
D) is important but not the immediate priority when there is protrusion of intestinal tissue.

Correct Answer: D

Rationale: The correct answer is D: Monitor the client's temperature every 4 hr. Neutropenia puts the client at high risk for infection due to low neutrophil count. Monitoring temperature helps detect early signs of infection.
Choice A is incorrect as sterile technique is required to prevent infection.
Choice B is incorrect as healthy visitors can introduce infections.
Choice C is incorrect as frequent room cleaning can disrupt the client's protective environment.

Correct Answer: A

Rationale: The correct answer is A: Pulmonary tuberculosis. This disease is required to be reported to the health department due to its highly contagious nature and potential for public health implications. Tuberculosis is transmitted through the air, making it a significant risk to the community. Reporting cases to the health department allows for proper monitoring, treatment, and prevention of further spread.

Choices B, C, and D are not required to be reported as they are not highly contagious or pose a significant public health threat compared to tuberculosis. Fibromyalgia syndrome is a chronic pain condition, Herpes simplex virus is common and not reportable, and Methicillin-resistant Staphylococcus aureus, while concerning, is typically managed within healthcare facilities and does not require reporting to the health department for public health monitoring.

Correct Answer:

Rationale:
To determine the correct answer, we must consider the implications of an epidural insertion. Decreasing the IV flow rate is essential to prevent hypotension which can occur due to the epidural anesthesia. Monitoring fetal heart rate is essential to ensure fetal well-being. Administering ampicillin IV and requesting ephedrine are not directly related to the client's condition post-epidural, so they are contraindicated. Placing the client in the left lateral position helps to optimize blood flow to the placenta and is essential post-epidural.
Therefore, the correct answer is .