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A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the
following actions is the first component of a safety plan?
Develop a code word that means "time to go."
INCORRECT
Developing a code to use when it is time to leave is important to protect the safety of the family members. However, this it is not the
first component of a safety plan.
• Identify signs of escalation of violence.
CORRECT
It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore,
this is the first component of the safety plan because it increases awareness of when danger is imminent and it is time to leave.
Have a predetermined place to go in the event of violence.
INCORRECT
Selecting a predetermined place to go in the event of violence is an essential part of the safety plan. However, it is not the first
component of the safety plan.
Keep a hidden packed bag of necessities.
INCORRECT
Keeping a hidden packed bag of necessities will make it easier for the client when out of the home. However, it is not the first
component of the safety plan.
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A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others.
Which of the following therapeutic nursing interventions is the priority?
Encourage expression of feelings.
INCORRECT
The nurse should encourage the child to express feelings in order to acknowledge them. However, another action is the priority.
Support the child's attendance at an assertiveness training group.
INCORRECT
The nurse should promote attendance at an assertiveness training group. However, another action is the priority.
Assist the child to perform relaxation breathing.
INCORRECT
The nurse should assist the child to perform relaxation breathing. However, another action is the priority.
• Reduce environmental stimuli.
CORRECT
The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an
attempt to de-escalate the behavior and prevent injury.
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A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the
following interventions should the nurse include in the plan?
Include a liquid supplement with meals.
INCORRECT
The nurse should include a liquid supplement for a client who is below their ideal body weight and might not be able to eat solid foods
at first or might need the additional nutrition to gain weight.
• Identify the client's trigger foods.
CORRECT
The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and
behavior that relate to the food.
Allow the client at least 1 hr for each meal.
INCORRECT
The nurse should limit the client's meal times to about 30 min to prevent putting excessive focus on food.
Weigh the client at bedtime each day.
INCORRECT
The nurse should weigh the client immediately after they wake up and void and prior to oral intake. The nurse should weigh the client
daily for the first week and then three times per week.
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