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Mark whether the statement by the student nurse indicates understanding or no understanding.
- A. If the client decides not to report their friend to the police, it is still a good idea to collect the evidence': Understanding
- B. Even if the client will not call the police, the nurse should advise the police of what has happened': No understanding
- C. The client has to consent in order for me to document his injuries in the chart': Understanding
- D. Consent is not required to collect evidence from a person who has been sexually assaulted': No understanding
- E. The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert': Understanding
Correct Answer: A,B,C,D,E
Rationale: A: Collecting evidence preserves options (Understanding). B: Reporting without consent violates autonomy (No understanding). C: Consent is required for documentation (Understanding). D: Consent is always required for evidence collection (No understanding). E: Exams require trained professionals (Understanding).
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An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?
- A. Cares for an older parent and her children
- B. Anxious to leave for personal appointments
- C. Takes naps in her car during lunch hour
- D. Works an average of 60 hours per week
Correct Answer: A
Rationale: Caring for an older parent and children simultaneously indicates significant caregiver role strain due to increased responsibilities. Anxiety, napping, and long work hours suggest stress but are less specific to caregiving demands.
A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?
- A. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol
- B. Take the medication with at least 8 ounces (240 mL) of water and limit alcohol consumption while taking this medication
- C. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol
- D. Take the medication each morning beginning 48 hours after your last drink of alcohol
Correct Answer: D
Rationale: Disulfiram must be started at least 48 hours after the last alcohol intake to prevent severe reactions, and alcohol must be completely avoided. Options A and B incorrectly suggest limited alcohol is safe. Option C risks reactions if alcohol is still in the system.
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
- A. Stimulation and dilated pupils
- B. Bradycardia and bradypnea
- C. Hallucinations and delusions
- D. Lethargy and depression
Correct Answer: A
Rationale: Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness. Bradycardia and bradypnea are not typical, as cocaine causes tachycardia and increased respiratory rate. Hallucinations and delusions are more associated with hallucinogens or psychotic disorders. Lethargy and depression occur during the 'crash' phase, not the immediate effects of cocaine use.
What symptoms are consistent with long-term rape trauma? Select all that apply.
- A. Social withdrawal
- B. Exaggerated startle response
- C. Intrusive thoughts
- D. Avoidance of places associated with the assault
Correct Answer: A,B,C,D
Rationale: A: Social withdrawal reflects ongoing distress. B: Exaggerated startle response persists post-trauma. C: Intrusive thoughts are unwanted trauma-related memories. D: Avoidance of trauma-associated places is a protective mechanism. All are hallmark long-term symptoms of rape-trauma syndrome.