Nokea
A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- A. Suicide risk
- B. Socioeconomic status
- C. Coping patterns
- D. Support systems
- E. Alcohol use
Correct Answer: A, C, D, E
Rationale: Suicide risk, coping patterns, support systems, and alcohol use are important considerations in abuse assessments. Socioeconomic status is not always a direct indicator.
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A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
- A. "I need to make sure that the potential victim is warned."
- B. "I need to keep the information confidential due to the client's right to privacy."
- C. "I can only discuss the client’s threats with a court order."
- D. "I should verbally report this information to the psychiatrist."
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.
A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statements should the nurse make?
- A. "I understand your grief. I lost a baby also."
- B. "You may hold your baby as long as you want."
- C. "I have called for the chaplain to come and stay with you."
- D. "This is for the best. Your baby was very ill."
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Offering the client the option to hold the stillborn baby allows for the initiation of the grieving process and provides closure. It shows empathy and respect for the client's loss, allowing them to spend time with their baby and say goodbye. This statement acknowledges the client's emotions and offers them control over their grieving process.
Summary of Incorrect Choices:
A: Sharing personal experiences may unintentionally minimize the client's grief and shift the focus away from them.
C: While spiritual support may be beneficial, it may not align with the client's beliefs or preferences.
D: Telling the client that the stillbirth is for the best may come off as insensitive and dismissive of their feelings, causing further distress.
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.
A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
- A. Move the client to a private area so the conversation will not be disturbed.
- B. Use clarification to determine what the client is feeling.
- C. Speak to the client using an authoritative voice.
- D. Maintain constant eye contact with the client.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.
Which action is most therapeutic for a client with panic-level anxiety?
- A. Suggest the client rest in bed
- B. Remain with the client
- C. Medicate the client with a sedative
- D. Have the client join a therapy group
Correct Answer: B
Rationale: The correct answer is B: Remain with the client. This is the most therapeutic action because it provides immediate reassurance and support to the client, helping to reduce feelings of isolation and fear during a panic attack. By staying with the client, you can offer comfort and help them feel safe and supported.
Choice A is incorrect as suggesting the client rest in bed may not address their immediate needs during a panic attack. Choice C, medicating the client with a sedative, may provide short-term relief but does not address the underlying causes of the anxiety. Choice D, having the client join a therapy group, is not suitable during a panic attack as the client needs immediate support and intervention.