Nokea
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
- A. help the client bathe and change into fresh clothing before the examination begins
- B. preserve any evidence, including clothing, and take photographs of injuries as appropriate
- C. assure the client that surviving the assault is most important, and she did what was needed to stay alive
- D. take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
- E. tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (B), providing reassurance (C), and ensuring a private setting (D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.
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A client diagnosed with chronic kidney disease (CKD) has been told that hemodialysis will be required. The client becomes angry and states, 'I'll never be the same now.' Based on this information, which should the nurse identify as the client's primary concern?
- A. Anxiety about the hemodialysis
- B. Inability to think clearly because of the treatments needed
- C. Potential for noncompliance because of concerns about the disease
- D. Altered body image because of the physical changes that may occur
Correct Answer: D
Rationale: A client with a renal disorder such as CKD may become angry in response to the permanence of the condition. Because of the physical changes and the change in lifestyle that may be required to manage a severe renal condition, the client may experience an altered body image. Anxiety is not appropriate because the client is exhibiting anger at this time. The client is not cognitively impaired, eliminating option 2, and is not stating a refusal to undergo therapy, so eliminate option 3.
A client experiencing urticaria (hives) and pruritus states to the nurse, 'What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy.' Which statement made by the nurse is the most therapeutic?
- A. You're troubled that this will extend into your wedding?
- B. It's probably just due to prewedding jitters. You'll be fine.
- C. The antihistamine will help a great deal, just you wait and see.
- D. Do you think this would really be something that could ruin your wedding?
Correct Answer: A
Rationale: The therapeutic communication technique that the nurse uses in option 1 is reflection. In option 2, the nurse minimizes the client's anxiety and fears. In option 3, the nurse talks about antihistamines and asks the client to 'wait and see.' This is nontherapeutic because the nurse is making promises that may not be kept. In addition, the response is closed-ended and shuts off the client's expression of feelings. In option 4, the nurse responds without sensitivity.
The nurse is caring for a client with a history of schizophrenia. The nurse asks the client if he is ready to eat his lunch. The client responds, 'Rain, train, down the drain, Jane's brain.' The nurse recognizes this type of speech pattern as which type?
- A. echolalia
- B. word salad
- C. neologisms
- D. clang association
Correct Answer: D
Rationale: Clang association is characterized by words chosen for their sound (e.g., rhyming or alliteration) rather than meaning, as seen in the client's response.
The nurse provides care for a client diagnosed with substance abuse. The nurse recognizes the client is using projection as a defense mechanism when the client makes which statement?
- A. There is genetic predisposition in my family to alcoholism.
- B. My spouse takes handfuls of medications, and I don't do that.
- C. I have one or two glasses of wine at dinner with my spouse.
- D. Many psychologists do not believe addiction is a disease.
Correct Answer: B
Rationale: Projection involves attributing one's own undesirable behaviors to others. The client blaming their spouse for excessive medication use reflects projection by deflecting their own substance abuse issues onto another person.
The nurse is caring for a client diagnosed with acute pulmonary edema. Which psychosocial strategy should the nurse plan to incorporate into the care of the client?
- A. Reducing anxiety
- B. Increasing fluid volume
- C. Decreasing cardiac output
- D. Promoting a positive body image
Correct Answer: A
Rationale: Reducing anxiety will help the client during treatment to increase cardiac output and decrease fluid volume. When cardiac output falls as a result of acute pulmonary edema, the sympathetic nervous system is stimulated. Stimulation of the sympathetic nervous system results in the fight-or-flight reaction, which further impairs cardiac function. A disturbed body image is not a common problem among clients with acute pulmonary edema.