Nokea
A young adult female client is admitted to the Emergency Department after being raped in a shopping center parking lot. The client expresses no suicidal ideation but expresses feelings of self-blame for not taking precautions when going to her car. According to theorists, such as Maslow and Erikson, this client is struggling with which issue?
- A. Self-absorption.
- B. Self-actualization.
- C. Self-control.
- D. Self-esteem.
Correct Answer: D
Rationale: Self-esteem is most related to feelings of self-blame, as the client struggles with self-worth post-trauma.
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The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?
- A. A summary of the client's feelings.
- B. The client's significant other's statement.
- C. A general description.
- D. Photographs.
Correct Answer: D
Rationale: Photographs provide objective and visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.
A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?
- A. Sit in the chair next to the client.
- B. Listen to what the client is saying.
- C. Escort the client to his room.
- D. Administer a PRN sedative.
Correct Answer: B
Rationale: Listening to what the client is saying helps understand the hallucinations' content, providing insight for appropriate intervention.
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
- A. Determine the client's reason for attempting suicide.
- B. Obtain the client's serum hydrocodone/acetaminophen level.
- C. Encourage the client to increase fluid intake.
- D. Observe the client for further narcotic effects.
Correct Answer: A
Rationale: Determining the client's reason for attempting suicide is the highest priority to understand underlying issues and plan appropriate interventions to prevent recurrence.
A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant amitriptyline that he uses to help him sleep. After reviewing the assessment findings with the healthcare provider, a serum creatinine is obtained. Which information supports the reason for this laboratory test?
- A. Creatinine can measure how the body is metabolizing the lithium in the liver.
- B. The effects of amitriptyline can promote and potentiate the risk of lithium toxicity.
- C. The combination of lithium and amitriptyline may need to be changed if creatinine is high.
- D. Lithium is excreted by the kidneys, and creatinine is related to kidney functioning.
Correct Answer: D
Rationale: Lithium is excreted by the kidneys, and monitoring creatinine levels assesses renal function, guiding dosage to prevent toxicity.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy.
- B. Demonstrates effective ways to cope with anxiety.
- C. Takes all antianxiety medications as prescribed.
- D. Learns methods of relaxation to reduce anxiety.
Correct Answer: B
Rationale: Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.