Nokea
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. Inform the client that because she is underage, she is at fault for attending a party where alcohol was served
- B. Ask the client if anyone witnessed the event because the client was intoxicated and might not remember correctly
- C. Inform the client that it was not her fault, and support the client through the physical examination
- D. Question whether the woman had consensual sex and now just feels guilty
Correct Answer: C
Rationale: Supporting the client and affirming that the rape was not her fault is critical, as acquaintance rape is serious and not negated by alcohol consumption.
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Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?
- A. This diet can be used when there is close medical supervision.'
- B. This is a long-term treatment measure that assists obese people who can't lose weight.'
- C. The VLCD consists of solid food items that are pureed to facilitate digestion and absorption.'
- D. A VLCD contains very little protein.'
Correct Answer: A
Rationale: VLCDs are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates to spare protein and prevent ketosis.
A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:
- A. immediately contact child protective services.
- B. provide the mother with literature about child care.
- C. consult a therapist to help the mother work out her fears.
- D. refer the mother to parenting classes.
Correct Answer: D
Rationale: Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents' social contacts and teach about community resources.
A client tells the nurse that his wife's nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?
- A. Tell me more specifically about her complaints.
- B. Can you think why she might nag you so much?
- C. I'll help you think about how to bring this up yourself tomorrow afternoon.
- D. Why do you want me to initiate this in tomorrow's session rather than you?
Correct Answer: C
Rationale: The client needs to learn how to communicate directly with his wife about her behavior. The nurse's assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation. Choices 1 and 2 inappropriately direct attention away from the client and toward his wife, who isn't present. Choice 4 implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client. Instead of focusing on his problems, he'll waste precious time convincing the nurse that he or she should do his work.
During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
- A. inquire about foods the child is eating.
- B. ask about the possibility of sexual abuse.
- C. request to see the type of bottle used for feedings.
- D. question the parent about objects the child plays with.
Correct Answer: B
Rationale: Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechiae) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse.
A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: Asking the client to describe the hallucinations validates their experience and provides insight into their condition, aiding therapeutic communication. Touching may be intrusive, leaving them alone is non-therapeutic, and denying the voices dismisses their reality.