Nokea
The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?
- A. A summary of the client's feelings.
- B. The client's significant other's statement.
- C. A general description.
- D. Photographs.
Correct Answer: D
Rationale: Photographs provide objective and visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.
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A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care? (Select all that apply)
- A. Shielding the client from direct sunlight when outdoors.
- B. Gradually withdrawing the medication over several days.
- C. Enforcing a fluid restriction during dosage adjustment.
- D. Increasing the dosage if the white blood cell count drops.
Correct Answer: A,B
Rationale: Shielding from sunlight prevents sunburn due to haloperidol's photosensitivity, and gradual withdrawal avoids symptom worsening.
A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I'm going to shoot myself.†Which intervention should the nurse implement?
- A. Inquire about the client's support system.
- B. Ask the client to repeat his comment.
- C. Stop the client from leaving the ED.
- D. Record the statement in the client's chart.
Correct Answer: C
Rationale: Stopping the client from leaving the ED is the priority to ensure safety and prevent potential self-harm based on the overheard statement.
The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?
- A. Reinforce personal strengths observed in the client.
- B. Suggest ways to problem solve adapting to the new home.
- C. Help the client know they will not always feel this way.
- D. Inquire respectfully about the events of the departure.
Correct Answer: D
Rationale: Inquiring respectfully about the events of departure is critical to understand potential traumatic experiences contributing to the client's anxiety.
After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?
- A. Instruct the client to reduce the volume of his voice.
- B. Accompany the client to a quiet area of the unit.
- C. Encourage the client to attend a support group.
- D. Administer a PRN sedative by injection.
Correct Answer: B
Rationale: Accompanying the client to a quiet area provides a calming environment, helping to deescalate the client's agitated state.
An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?
- A. Tell the client to call Adult Protective Services if his son's abuse continues.
- B. Verify the client's report by determining if there is physical evidence of abuse.
- C. Refer the client to a program for victims of domestic violence.
- D. Assist the client in developing an emergency safety plan.
Correct Answer: D
Rationale: Assisting the client in developing an emergency safety plan is the most important intervention to ensure immediate safety in the context of ongoing abuse.