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The nurse is caring for a client who experienced a sexual assault and has posttraumatic stress disorder. The client states, 'It is all my fault. I should not have accepted a drink from a stranger I met at a bar.' Which of the following responses would be most appropriate for the nurse to make?
- A. Those thoughts are not good for you. You should try to stop thinking about the assault.
- B. You have to stop blaming yourself for the assault so you can move on with your life.
- C. It may take time to overcome your thoughts and feelings related to the assault.
- D. You could not have anticipated the assault. You did not deserve or ask for it.
Correct Answer: D
Rationale: This response validates the client's feelings while gently correcting self-blame, reinforcing that the assault was not their fault and promoting a supportive therapeutic environment.
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A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives shift report to the oncoming nurse and conveys that the client's current Glasgow Coma Scale score is a '10.' Which other information is most important for the reporting nurse to include?
- A. Client's blood pressure was 120/80 mm Hg and pulse was 82/min recently
- B. Client's Glasgow Coma Scale score was '11' one hour ago
- C. Client believes that the current surroundings are a racetrack
- D. Client is allergic to penicillin and vancomycin
Correct Answer: B
Rationale: A decrease in Glasgow Coma Scale score from 11 to 10 in one hour indicates worsening neurological status, possibly due to increasing intracranial pressure, requiring urgent reporting.
The mother of a 4-month-old infant calls the physician's office reporting that her child has a temperature of 101°F and a rash that is blanchable and doesn't itch. What does the LPN expect will be ordered for this child?
- A. Aspirin
- B. Ibuprofen
- C. Acetaminophen
- D. Antibiotics
Correct Answer: C
Rationale: Acetaminophen is safe for fever in infants, addressing the temperature while the non-itchy, blanchable rash is monitored, likely viral.
The nurse is discussing preventive health care with a group of women. Which woman should the nurse advise to have a mammogram?
- A. A 20-year-old who says her breasts hurt before her period
- B. A 25-year-old who was hit in the breast area by a ball
- C. A 32-year-old who has been breastfeeding for 12 months
- D. A 52-year-old who has no breast symptoms
Correct Answer: D
Rationale: Mammograms are recommended starting at age 50 for asymptomatic women per standard guidelines, making the 52-year-old the priority.
A client with a partial bowel obstruction has a Miller-Abbot tube inserted to decompress the bowel. While the tube is in place, the nurse should give priority to:
- A. Using only normal saline to irrigate the tube every 4 hours
- B. Advancing the tube 3-4 inches as ordered by the physician
- C. Changing the tape securing the tube to the client's face daily to prevent skin breakdown
- D. Attaching the tube to high constant suction
Correct Answer: C
Rationale: Preventing skin breakdown by changing the tape daily is critical to avoid tissue damage around the insertion site. Irrigation and suction settings depend on physician orders, and advancing the tube is not a nursing priority without specific instructions.
During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?
- A. leave a book about relaxation techniques
- B. write out a daily exercise routine for them to assist the client to do
- C. list actions to improve the client's daily nutritional intake
- D. suggest communication strategies
Correct Answer: D
Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.