Nokea
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.
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The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse's best response?
- A. I need to find out the client's preferences first.
- B. Shave him only after you have bathed him.
- C. Use the electric razor when you shave him.
- D. Avoid shaving him. I need a doctor's order.
Correct Answer: A
Rationale: A: Removal of facial hair varies based on personal and cultural preferences, which should be assessed first. B: Bathing order is irrelevant without preferences. C: Electric razors are safe but preferences are unknown. D: Shaving does not require a doctor's order.
Perineal care to a female client by the nurse can be performed:
- A. Without gloves, pouring water from a sterile bottle
- B. Without gloves, having the client perform all care
- C. With gloves, washing the perineal area from front to back
- D. With gloves, washing the perineal area from back to front
Correct Answer: C
Rationale: Perineal care requires gloves and washing from front to back to prevent bacterial contamination of the urethra, ensuring infection control.
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.
When making an occupied bed, it is important for the nurse to:
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy.
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct Answer: B
Rationale: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.
The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse's best response?
- A. This is an expected finding after administration of barium.
- B. Describe any abdominal pain you had when passing the stool.
- C. What foods or fluids did you eat after you completed the test?
- D. You need to increase the amount of water you are drinking.
Correct Answer: A
Rationale: A: Pale stools are expected due to residual barium. B: Pain doesn't cause pale stools. C: Diet doesn't affect barium-related stool color. D: Water aids barium passage but isn't indicated for soft stools.