Nokea
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
You may also like to solve these questions
A nurse is speaking with a client experiencing anxiety. Which of the following responses is most therapeutic?
- A. "Most clients with anxiety benefit from lying down."
- B. "Come with me to an area where we can talk without interruption."
- C. "Providers usually recommend relaxation exercises for clients who are upset."
- D. "An antianxiety pill works best for situations like this."
Correct Answer: B
Rationale: The correct answer is B. Bringing the client to an area for uninterrupted conversation shows active listening and support. It promotes a safe space for the client to express feelings and reduces anxiety. Choice A is incorrect as it assumes all clients benefit from lying down, which may not be true. Choice C is incorrect because recommending relaxation exercises may not address the client's immediate needs. Choice D is incorrect as medication should not be the first response for managing anxiety without exploring other options first.
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
- A. "I plan to sit on a park bench for a few minutes each day."
- B. "I can try participating in group therapy every week."
- C. "I will join a book club in my neighborhood."
- D. "I should avoid entering elevators and other closed spaces."
Correct Answer: A
Rationale: The correct answer is A: "I plan to sit on a park bench for a few minutes each day." This statement indicates the client's understanding of gradual exposure therapy, a common treatment for agoraphobia. Exposure to feared situations in a controlled manner helps desensitize the client to their anxiety triggers. Sitting on a park bench signifies a small step towards facing the fear of open spaces. Choices B, C, and D do not directly address the core issue of agoraphobia or the specific treatment approach. Group therapy and joining a book club may be beneficial but do not target the fear of open spaces. Avoiding elevators and closed spaces is a safety behavior that reinforces the fear and hinders recovery.
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?
- A. A client who has been taking amitriptyline for 3 months for depression.
- B. A client exhibiting psychotic behavior.
- C. A client admitted 12 hours ago for acute mania.
- D. A client who is experiencing alcohol intoxication.
Correct Answer: A
Rationale: Clients who have stabilized with medication are appropriate for group therapy.
A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
- A. Significant change in weight
- B. Hyperexcitability
- C. Exaggerated response to stimuli
- D. Attention-seeking behavior
Correct Answer: A
Rationale: The correct answer is A: Significant change in weight. In major depressive disorder (MDD), clients commonly experience appetite changes, leading to weight gain or weight loss. This is due to disturbances in their eating patterns. Weight changes can be a result of decreased interest in food or emotional eating. This is a key symptom to monitor in clients with MDD. Hyperexcitability (B), exaggerated response to stimuli (C), and attention-seeking behavior (D) are not typical findings in clients with MDD. Hyperexcitability and exaggerated response to stimuli are more often associated with conditions like anxiety disorders, while attention-seeking behavior is more commonly seen in personality disorders.
A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?
- A. "The legal requirement for client confidentiality ceases if the client is deceased."
- B. "Staff members are required to divulge information to attorneys if they call for information."
- C. "Health care workers are not required to answer a court's requests for information about a client's disclosure."
- D. "Providers are required to warn individuals if the client threatens harm."
Correct Answer: D
Rationale: The correct answer is D because it refers to the duty to warn, which is a legal exception to client confidentiality. When a client poses a serious and imminent threat of harm to others, healthcare providers have a duty to warn those at risk. This exception prioritizes public safety over confidentiality.
Explanation of why other choices are incorrect:
A: Incorrect. Confidentiality typically extends even after a client's death to protect their privacy rights and maintain trust in healthcare providers.
B: Incorrect. Disclosing information to attorneys without client consent violates confidentiality unless required by law or court order.
C: Incorrect. Healthcare workers are generally required to comply with court requests for information unless protected by a legal privilege.
E, F, G: Not provided.