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An 8-year-old is admitted to the hospital after being sexually abused by an adult family member. The child is withdrawn and appears frightened. Which describes the best plan for the initial nursing encounter to convey concern and support?
- A. Introduce self and explain to the child that she or he is safe now here in the hospital.
- B. Introduce self and tell the child that you would like to sit with the child for a little while.
- C. Introduce self and then ask the child to express how she or he feels about the events leading up to this hospital admission.
- D. Introduce self, explain your role, and ask the child to act out the sexual encounter with the abuser with the use of art therapy.
Correct Answer: B
Rationale: Victims of sexual abuse may exhibit fear and anxiety regarding what has just occurred. In addition, they may fear that the abuse could be repeated. When initiating contact with a child victim of sexual abuse who demonstrates a fear of others, it is best to convey a willingness to spend time and move slowly to initiate activities that may be perceived as threatening. After a rapport is established, the nurse may explore the child's feelings or use various therapeutic modalities to encourage the recounting of the sexual encounter. Option 2 conveys a plan for an initial encounter that establishes trust by sitting with the child in a nonthreatening atmosphere. Option 1 does not convey concern and support by the nurse. Options 3 and 4 may be implemented after trust and rapport are established.
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A 9-year-old child is hospitalized in traction for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development?
- A. Providing a music player
- B. Tutoring to keep the child up with schoolwork
- C. Providing a phone for calling family and friends
- D. Placing computer games, a television, and videos at the bedside
Correct Answer: B
Rationale: The developmental task of the school-age child is industry versus inferiority. The child achieves success by mastering skills and knowledge. Maintaining schoolwork provides for accomplishment and prevents feelings of inferiority that may be caused by lagging behind the rest of the class. The other options provide diversion and are of lesser importance for a child of this age.
The home health nurse visits a client with cancer undergoing anti-cancer treatment. The nurse asks how the client is coping, and the client cries and with an angry voice says, 'Nobody understands. I am hanging on, trying to take one day at a time, but it is all I can do to get up in the morning.' How does the nurse best respond?
- A. What kind of support do you think would be most helpful to you at this time?
- B. I would be upset too if the people around me didn't act like they cared.
- C. Dealing with family is a challenge, even for people who are feeling healthy.
- D. Why don't you attend a support group for women who are going through the same thing?
Correct Answer: A
Rationale: Asking about desired support empowers the client to express needs, addressing their feelings of being misunderstood. Empathizing without guidance, focusing on family, or suggesting a support group without client input is less client-centered.
The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
- A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
- B. Sit quietly in the client's room until the client leaves the bathroom.
- C. Allow the client to cry alone and leave the client in the bathroom.
- D. Talk to the client and attempt to find out why the client is crying.
Correct Answer: D
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.
The nurse plans care for a client diagnosed with anorexia nervosa. Which goal will the nurse make a priority for this client?
- A. Gain one-fourth pound (0.11 kg) per week.
- B. Maintain potassium balance between 3.5 and 5.0 mEq/L (3.5 to 5.0 mmol/L).
- C. Eat 50% of each meal.
- D. Identify a normal weight for height.
Correct Answer: A
Rationale: Gradual weight gain (0.25 lb/week) is the priority goal for anorexia, addressing malnutrition and physical health risks. Electrolyte balance and meal consumption are important but secondary, and identifying normal weight is a long-term cognitive goal.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
- A. Provide the client with a list of reliable internet sites that offer information on medications.
- B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
- C. Reassure the client that information about the medication is included in the written instructions.
- D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.
Correct Answer: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.