Nokea
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels 'as though the rape just happened yesterday.' Which statement is most appropriate for the nurse to use as a response?
- A. In reality, the rape did not just occur. It has been over 2 months now.'
- B. What can you do to alleviate some of your fears about being assaulted again?'
- C. In time, our goal will be to help you move on from these strong feelings about your rape.'
- D. Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.'
Correct Answer: D
Rationale: Option 4 allows for the client to express her ideas and feelings more fully and portrays a unhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe care environment. Although option 1 is true, it immediately blocks communication. Option 2 places the problem-solving totally on the client. Option 3 places the client's feelings on hold.
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A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
- A. Why did you take the medication?
- B. Can you share what is bothering you?
- C. How much medication did you take?
- D. Were you trying to kill yourself?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
- A. Do you have a death wish?'
- B. Do you wish your life was over?'
- C. Do you ever think about ending it all?'
- D. Do you have any thoughts of killing yourself?'
Correct Answer: D
Rationale: A lethality assessment requires direct communication between the client and the nurse concerning the client's intent. It is important to provide a question that is directly related to lethality. Euphemisms should be avoided.
When planning the care of the client diagnosed with thromboangiitis obliterans (Buerger's disease), the nurse incorporates information on which support service to best help the client cope with the lifestyle changes that are needed to control the disease process?
- A. Consult with a dietician
- B. Pain management clinic
- C. Smoking cessation program
- D. Referral to a medical social worker
Correct Answer: C
Rationale: Smoking is highly detrimental to the client with Buerger's disease, and clients are recommended to stop completely. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated when smoking stops. None of the remaining options are directly related to the physiology associated with this condition.
After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovering process after discharge. Which available resource should the nurse plan to tell the client and family about to best address their concerns?
- A. The United Way
- B. The client's local church
- C. The American Cancer Society Reach for Recovery
- D. The American Heart Association Mended Hearts Club
Correct Answer: D
Rationale: Most clients and families benefit from knowing that there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon, cardiologist, and nurse; cardiac rehabilitation programs; and community support groups such as the American Heart Association Mended Hearts Club, which is a nationwide program with local chapters. The United Way provides a wide variety of services to people who may not otherwise be able to afford them. The library normally does not provide resources for coping with the recuperative process. The American Cancer Society Reach for Recovery helps women recover after mastectomy.
The nurse is caring for a client who is having surgery the next morning. The client says, 'I'm really scared about surgery. I've never been put to sleep before and I'm afraid I might not wake up.' Which response by the nurse is the most therapeutic?
- A. Why are you worried about such a minor procedure?
- B. We can call the doctor and cancel the surgery if you would prefer.
- C. It's normal to be afraid of something new like surgery. Tell me how you feel.
- D. Don't worry, you have a really good doctor and he will see to it that nothing goes wrong.
Correct Answer: C
Rationale: Acknowledging fear as normal and encouraging the client to express feelings (C) is therapeutic, promoting open communication. Minimizing concerns (A), suggesting cancellation (B), or offering false reassurance (D) dismisses the client's emotions.