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A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply.)
- A. Contact the laboratory to obtain a blood sample.
- B. Prepare the client for a CT scan.
- C. Check the client’s pupil reactivity.
- D. Obtain a urine specimen.
- E. Perform a developmental screening test.
Correct Answer: A, B, C, D
Rationale: The correct interventions for a client experiencing alcohol intoxication are A, B, C, and D. A blood sample is crucial to assess alcohol levels. A CT scan may be needed to rule out head trauma or other underlying issues. Checking pupil reactivity can indicate neurological status. Obtaining a urine specimen helps assess kidney function and possible drug use. Choice E, performing a developmental screening test, is not relevant to the immediate care needs of an individual with alcohol intoxication.
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A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. "Tell me about the concerns that you have regarding your relationship."
- B. "You should try to see your partner’s point of view before your own."
- C. "We could develop a plan for how to talk about this with your partner."
- D. "Relationship difficulties are stressful and require effort to resolve."
Correct Answer: B
Rationale: The correct answer is B. This statement implies a bias towards the partner's perspective, potentially invalidating the client's feelings. The nurse should prioritize understanding the client's concerns first. A is correct as it encourages open communication. C shows proactive problem-solving. D acknowledges the challenges of resolving relationship issues.
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.
A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate?
- A. Offer to make arrangements for the Sacrament of the Sick.
- B. Prepare to stay with the client's body after death until family arrives.
- C. Arrange for a member of the client's faith to bathe the body after death.
- D. Post a sign on the client's door stating, “No Talking.”
Correct Answer: A
Rationale: The correct answer is A: Offer to make arrangements for the Sacrament of the Sick. This is appropriate because the client is a practicing Roman Catholic, and the Sacrament of the Sick is a sacrament in the Catholic faith administered to the sick or dying. Offering to arrange for this sacrament shows respect for the client's religious beliefs and provides spiritual comfort.
Choice B is incorrect because staying with the client's body after death is not necessarily a religious practice and may not align with the client's beliefs. Choice C is incorrect as it assumes the client's faith requires a specific individual to bathe the body, which may not be the case for all Roman Catholics. Choice D is incorrect as it is not relevant to the client's religious needs and may hinder communication during this sensitive time.
A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
- A. Enroll the client in a nutritional class on the unit.
- B. Weigh the client at the same time every morning.
- C. Ask the provider to arrange a consultation with the facility chaplain.
- D. Sit with the client during meals and snacks.
Correct Answer: D
Rationale: The correct answer is D: Sit with the client during meals and snacks. This option promotes a therapeutic relationship, encourages the client to eat, and provides emotional support. By sitting with the client, the nurse can monitor food intake, address any eating difficulties, and offer encouragement. This approach helps the client feel supported and valued, which can positively impact their nutritional intake.
Choice A is incorrect as a nutritional class may not address the client's immediate needs. Choice B is incorrect as weighing the client daily does not directly improve their nutritional status. Choice C is incorrect as involving the chaplain may not address the nutritional needs of the client.
A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 months. Which of the following interventions should the nurse take?
- A. Make a contract with the client not to drive over the speed limit.
- B. Call the local police and alert them to the client's car license plate number and the make and model of her car.
- C. Ask the client to "hand over the keys" to you and tell her that now she must use a cab or other public transportation until your next session.
- D. Inform the client that she cannot drink and drive.
Correct Answer: A
Rationale: The correct answer is A: Make a contract with the client not to drive over the speed limit. This intervention is appropriate as it establishes clear boundaries and expectations for the client's behavior, addressing the issue of multiple speeding tickets. By creating a contract, the nurse can work with the client to set specific goals and consequences for adhering to the speed limit. This method promotes accountability and helps the client understand the importance of safe driving practices.
Other choices are incorrect:
B: Calling the local police would breach confidentiality and trust, which is not ethical.
C: Taking away the client's keys may be seen as punitive and could lead to resistance or defiance.
D: While important, the issue of drinking and driving is not directly related to the client's speeding tickets.