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The emergency department nurse describes procedures and their purposes to the rape victim before they are implemented. What is the rationale for the nurse's action?
- A. It diminishes feelings of powerlessness.
- B. It tends to reduce the client's anxiety.
- C. It is a policy of the emergency department.
- D. It meets the client's need for teaching.
Correct Answer: A
Rationale: Explaining procedures empowers the victim by restoring some control, counteracting the powerlessness experienced during the assault.
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When the client begins crying and says, 'Nurse, I feel like I'm going to die,' which response is most therapeutic?
- A. You are having a panic attack.
- B. You don't want the physician to see you this way.
- C. Everyone feels frightened in an emergency.
- D. I'll stay with you until you feel better.
Correct Answer: D
Rationale: Staying with the client provides reassurance and support, directly addressing their fear and promoting a sense of security.
Which emotional responses are the parents most likely to experience immediately after the sudden death of their infant?
- A. Anger
- B. Guilt
- C. Fear
- D. Depression
Correct Answer: B
Rationale: Guilt is a common immediate response as parents often question their actions or feel responsible for the infant's death, reflecting early grief processing.
The nurse assesses the client every 15 minutes. What objective evidence will the nurse detect that indicates that the restraints are too tight? Select all that apply.
- A. The client reports being unable to move the right hand.
- B. The client's fingers and toes are pale.
- C. The client reports having pain.
- D. Capillary refill is greater than 6 seconds.
- E. There is excoriation around the wrist.
- F. The client reports numbness and tingling.
Correct Answer: B,D,F
Rationale: Pallor, prolonged capillary refill, and numbness indicate impaired circulation, suggesting restraints are too tight and compromising blood flow.
Which approach is best for managing the client's care?
- A. Use a nonjudgmental manner when cleaning the client of stool.
- B. Ask the client's spouse to perform hygiene measures.
- C. Hold the client responsible for all hygiene.
- D. Assign same-gender nurses to care for the client.
Correct Answer: A
Rationale: A nonjudgmental approach preserves the client's dignity, reducing embarrassment and supporting self-esteem during hygiene care.
The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door belligerent and demanding to visit the child. Which is the most appropriate nursing plan of action?
- A. Allow the parent to enter the room and see the child.
- B. Tell the parent that the HCP wants to speak with the parent first.
- C. Contact Social Services to report the parent’s abusive behavior.
- D. Initiate the emergency response system for behavioral situations.
Correct Answer: D
Rationale: Initiating the emergency response (D) ensures safety. Allowing entry (A) deferring to HCP (B) or reporting to Social Services (C likely already done) are inappropriate.