Nokea
If a rape victim desires medical treatment but objects to having evidence collected for criminal prosecution, which nursing action is most appropriate?
- A. Persuading the victim to reconsider the decision
- B. Proceeding because it is required
- C. Accepting the rape victim's wishes
- D. Advising the victim to use better judgment
Correct Answer: C
Rationale: Respecting the victim's autonomy honors their right to make decisions about their care, aligning with ethical nursing practice.
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The client undergoing a routine physical exam asks the nurse if taking the dietary supplement androstenedione sometimes referred to as “andro” would help to get in shape for football season. Which statement by the nurse is best?
- A. “Androstenedione is considered a dietary supplement and therefore is not guaranteed safe by FDA standards.”
- B. “Benefits of androstenedione have not been proven. In fact there appear to be more negative effects than benefits.”
- C. “Taking androstenedione supplements is similar to taking vitamin supplements. Andro is found in meats so the tablet forms are safe.”
- D. “Androstenedione supplements have been proven to be perfectly safe because it is a naturally occurring hormone that is the precursor for testosterone.”
Correct Answer: B
Rationale: Androstenedione lacks proven benefits and has negative effects (B). FDA oversight (A) is partial meat comparison (C) is false and safety (D) is unproven.
The client is receiving clonidine to relieve selected symptoms of opioid withdrawal. Which assessment is most important for the nurse to complete before administering clonidine?
- A. Check for presence of dilated pupils
- B. Investigate recent nausea or vomiting
- C. Test for abnormally heightened reflexes
- D. Verify that the blood pressure is not low
Correct Answer: D
Rationale: Clonidine requires BP check (D) to avoid hypotension. Dilated pupils (A) nausea (B) and reflexes (C) don’t contraindicate it.
What nursing approach is most beneficial for helping the nursing assistant at this time?
- A. Sending the nursing assistant home for the rest of the shift
- B. Terminating the nursing assistant from this type of work
- C. Allowing the nursing assistant to express feelings
- D. Asking the nursing assistant to help with postmortem care
Correct Answer: C
Rationale: Allowing expression of feelings helps the assistant process grief, supporting emotional well-being after a distressing event.
The nurse is interacting with the client who abuses methamphetamine. The client states “I don’t plan to quit meth. I can work for days when I’m high.” Which is the best response by the nurse?
- A. “You’ll exhaust yourself working days when you’re high.”
- B. “You can’t see the real problem yet because you’re in denial.”
- C. “You say you don’t plan to quit. Do you think using drugs helps you?”
- D. “Good point. You probably do work long hours while you are on meth.”
Correct Answer: C
Rationale: Restating neutrally (C) encourages reexamination. Directives (A) labeling denial (B) or agreeing (D) are less effective.
The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse’s primary goal of this seclusion?
- A. Assist the client in regaining self-control
- B. Assure the safety of the client and others
- C. Regain control over the unit’s environment
- D. Provide a consequence for the client’s behavior
Correct Answer: B
Rationale: Safety of client and others (B) is the primary seclusion goal by reducing stimuli. Self-control (A) and unit control (C) are outcomes and punishment (D) is inappropriate.