Nokea
When the rape victim arrives at the emergency department, which nursing action is best for relieving the client's anxiety?
- A. Determine the victim's last date of menstruation.
- B. Collect evidence for criminal prosecution.
- C. Assess the extent of the client's injuries.
- D. Stay with the client at all times.
Correct Answer: D
Rationale: Remaining with the victim provides emotional support and a sense of safety, directly addressing anxiety during a traumatic experience.
You may also like to solve these questions
Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?
- A. “Let’s not prejudge him. His medication should help him control his behavior.”
- B. “I will be very attentive to his behavior monitoring it for any signs of escalation.”
- C. “It may be hard but we need to appear calm and nonthreatening but alert to his behavior.”
- D. “As staff we are all trained to manage violent clients and we can handle any crisis behavior.”
Correct Answer: C
Rationale: Appearing calm and nonthreatening (C) addresses staff concerns and guides management. Prejudging (A) personal monitoring (B) or overconfidence (D) dismiss staff fears.
Which action is best to use initially when trying to help the angry client maintain self-control?
- A. Administer a sedative.
- B. Apply four-point restraints.
- C. Use a calm voice and approach.
- D. Place the client in seclusion.
Correct Answer: C
Rationale: A calm voice and approach de-escalates anger by creating a non-threatening environment, encouraging the client to regain control.
Multiple clients are being cared for on the behavioral health unit. In which circumstances should the nurse plan the therapeutic use of seclusion and/or restraints? Select all that apply.
- A. The client asks to be placed in seclusion.
- B. The client expresses the likelihood of self-injury.
- C. The staff feels the client is likely to harm others.
- D. A legally detained client is threatening to “escape.”
- E. The staff identifies seclusion as a consequence of the client’s behavior.
- F. The client’s threatening behavior is negatively affecting the therapeutic milieu.
Correct Answer: A, B ,C, D
Rationale: Seclusion/restraints are therapeutic for client request (A) self-injury risk (B) harm to others (C) or escape threats (D). Punishment (E) or milieu disruption (F) alone are not indications.
Which of the following historical data is the greatest risk factor for hypochondriasis?
- A. The client experienced parental neglect as a child.
- B. The client has a sibling with schizophrenia.
- C. The client experienced parental overprotection as a child.
- D. The client has a history of substance abuse.
Correct Answer: C
Rationale: Parental overprotection can foster excessive health concerns, contributing to hypochondriasis by reinforcing anxiety about physical symptoms.
The nurse is in the working phase of a relationship with the client being treated for substance abuse. Which intervention would be appropriate during this phase of treatment?
- A. Assessing the client’s readiness to change substance-abusing behavior
- B. Evaluating the effectiveness of the client’s newly adapted coping skills
- C. Confronting the client’s denial that substances have negatively impacted daily life
- D. Determining the extent to which substances have impaired the client’s functioning
Correct Answer: C
Rationale: Confronting denial (C) is key in the working phase. Readiness (A) and impairment (D) are assessment phase evaluation (B) is final phase.