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A nurse is caring for a client in the emergency department who states she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
- A. Conduct a pregnancy test
- B. Request mental health consultation for the client
- C. Provide a trained advocate to stay with the client
- D. Offer prophylactic medication to prevent STI’s
- E. A client who describes having persistent feelings of anger about the hurricane.
Correct Answer: A
Rationale: The correct answer is A: Conduct a pregnancy test. This action is important to assess the client's risk of pregnancy resulting from the sexual assault. Pregnancy testing is crucial for timely decision-making regarding emergency contraception. This step is a priority in the care of a sexual assault survivor. It ensures appropriate medical intervention and support for the client's physical and emotional well-being.
Summary of other choices:
B: Requesting mental health consultation is important but not the immediate next step.
C: Providing a trained advocate is valuable for support but does not address the urgent medical needs of the client.
D: Offering prophylactic medication for STIs is important but not the immediate next step before assessing pregnancy risk.
E: This choice is unrelated to the situation described and should not be considered in this context.
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A nurse is providing teaching to a client who has panic disorder and is receiving alprazolam. Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach
- B. Avoid activities that require alertness
- C. Stop taking the medication if dizziness occurs
- D. Take an additional dose if anxiety increases
Correct Answer: B
Rationale: The correct answer is B: Avoid activities that require alertness. This is important because alprazolam is a benzodiazepine that can cause drowsiness and impair cognitive function. By avoiding activities that require alertness, the client can prevent accidents or injuries.
A: Taking the medication on an empty stomach is not necessary for alprazolam.
C: Stopping the medication if dizziness occurs is not recommended without consulting a healthcare provider.
D: Taking an additional dose if anxiety increases can lead to overdose and is not safe.
Therefore, choice B is the most appropriate instruction to include in teaching the client with panic disorder taking alprazolam.
A nurse is providing teaching to a client who has depression and a new prescription for amitriptyline. Which of the following statements should the nurse include?
- A. Take this medication at bedtime
- B. Expect to see improvement within 24 hours
- C. Avoid eating foods high in tyramine
- D. Stop the medication once you feel better
Correct Answer: A
Rationale: The correct answer is A: Take this medication at bedtime. Amitriptyline is a tricyclic antidepressant that can cause drowsiness and sedation, so taking it at bedtime can help minimize these side effects. It also helps improve adherence to the medication regimen. Choice B is incorrect because it takes several weeks to see the full effects of amitriptyline, not within 24 hours. Choice C is incorrect because tyramine restriction is typically associated with MAOIs, not tricyclic antidepressants like amitriptyline. Choice D is incorrect because abruptly stopping amitriptyline can lead to withdrawal symptoms and a potential relapse of depression.
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?
- A. Increased energy
- B. Restlessness
- C. Depersonalization
- D. Euphoric mood
Correct Answer: B
Rationale: The correct answer is B: Restlessness. In generalized anxiety disorder, clients often experience restlessness due to excessive worry and fear. This can manifest as fidgeting, inability to relax, and feeling on edge. Restlessness is a common symptom seen in individuals with this disorder. Increased energy (choice A) is less likely as anxiety tends to deplete energy. Depersonalization (choice C) is more commonly associated with dissociative disorders, not generalized anxiety disorder. Euphoric mood (choice D) is not typically seen in clients with generalized anxiety disorder, as they are more likely to feel tense and worried.
A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
- A. Slurred speech
- B. Hypotension
- C. Bradycardia
- D. Hyperthermia
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. Heroin withdrawal can lead to hyperthermia due to increased metabolic activity, dehydration, and dysregulation of the body's temperature control mechanisms. Slurred speech (A) is not a typical manifestation of heroin withdrawal. Hypotension (B) and bradycardia (C) are more commonly associated with opioid overdose rather than withdrawal. In withdrawal, the client may actually experience hypertension and tachycardia due to increased sympathetic activity.
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include?
- A. Position the mattress on the floor
- B. Install sensor devices on outside doors
- C. Encourage physical activity prior to bedtime
- D. Put locks at top of doors
Correct Answer: A
Rationale: The correct answer is A: Position the mattress on the floor. Placing the mattress on the floor reduces the risk of injury if the client falls out of bed while wandering at night. This option prioritizes safety by minimizing the distance of potential falls. Installing sensor devices on outside doors (B) may alert the caregiver but does not directly address the risk of falls. Encouraging physical activity prior to bedtime (C) could increase agitation and wandering behavior. Putting locks at the top of doors (D) could pose a safety risk if emergency access is needed.