Nokea
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
- A. help the client bathe and change into fresh clothing before the examination begins
- B. preserve any evidence, including clothing, and take photographs of injuries as appropriate
- C. assure the client that surviving the assault is most important, and she did what was needed to stay alive
- D. take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
- E. tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (B), providing reassurance (C), and ensuring a private setting (D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.
You may also like to solve these questions
A client who has a history of depression has been prescribed nadolol for the management of angina pectoris. Which consideration is most important when the nurse plans to counsel this client about the effects of this medication?
- A. Risk of tachycardia
- B. Probability of fatigue
- C. High incidence of hypoglycemia
- D. Possible exacerbation of depression
Correct Answer: D
Rationale: Clients with depression or a history of depression have experienced an exacerbation of depression after beginning therapy with beta-adrenergic blocking agents. These clients should be monitored carefully if these agents are prescribed. The medication would cause bradycardia rather than tachycardia. Fatigue is a possible side effect, but it is not the most important item. Hypoglycemia is a sign that is masked with beta blockers.
The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate?
- A. Prepare a schedule of activities and monitor the client's participation in the activities.
- B. Encourage the client to choose the client's own activities.
- C. Allow the client time to get acclimated to the milieu before scheduling activities.
- D. Allow the client to rest quietly to restore energy level.
Correct Answer: C
Rationale: Allowing time to acclimate helps the client adjust to the new environment, reducing stress and supporting engagement, especially given their cognitive and social challenges. Scheduling activities or encouraging choices may be premature, and rest alone does not address isolation.
The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?
- A. Monitor vital signs every 15 minutes.
- B. Administer bromocriptine as prescribed.
- C. Administer the haloperidol as prescribed.
- D. Assess the client's level of consciousness.
Correct Answer: B
Rationale: The symptoms suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to haloperidol. Administering bromocriptine, if prescribed, is the priority to reverse NMS. Monitoring, continuing haloperidol, or assessing consciousness delays critical intervention.
A preschool child is placed in traction for a femur fracture. The child has started bedwetting, even though the child has been toilet trained for a year. The mother is very upset about the situation. The nurse explains to the mother that this behavior should be recognized as which psychosocial adaptation?
- A. A body image disturbance
- B. Attention-seeking behavior
- C. Opposition to authority figures
- D. Regressing to earlier developmental behavior
Correct Answer: D
Rationale: The monotony of immobilization can lead to sluggish intellectual and psychomotor responses. Regressive behaviors are not uncommon in immobilized children, and they usually do not require professional intervention. Body image may or may not be affected by long-term immobilization, but it does not relate to the information presented in the question. The remaining options are not relevant to the described situation.
The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
- A. Help the client express fears.
- B. Assess the nature of the client's fears.
- C. Help the client identify coping mechanisms that were successful in the past.
- D. Document verbal and nonverbal expressions of fear and other significant data.
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.