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The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
- A. Document that the client responds to the painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the health care provider.
Correct Answer: A
Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.
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An 8-year-old is admitted to the hospital after being sexually abused by an adult family member. The child is withdrawn and appears frightened. Which describes the best plan for the initial nursing encounter to convey concern and support?
- A. Introduce self and explain to the child that she or he is safe now here in the hospital.
- B. Introduce self and tell the child that you would like to sit with the child for a little while.
- C. Introduce self and then ask the child to express how she or he feels about the events leading up to this hospital admission.
- D. Introduce self, explain your role, and ask the child to act out the sexual encounter with the abuser with the use of art therapy.
Correct Answer: B
Rationale: Victims of sexual abuse may exhibit fear and anxiety regarding what has just occurred. In addition, they may fear that the abuse could be repeated. When initiating contact with a child victim of sexual abuse who demonstrates a fear of others, it is best to convey a willingness to spend time and move slowly to initiate activities that may be perceived as threatening. After a rapport is established, the nurse may explore the child's feelings or use various therapeutic modalities to encourage the recounting of the sexual encounter. Option 2 conveys a plan for an initial encounter that establishes trust by sitting with the child in a nonthreatening atmosphere. Option 1 does not convey concern and support by the nurse. Options 3 and 4 may be implemented after trust and rapport are established.
The nurse is developing a plan of care for a client scheduled for an above-the-knee leg amputation. Which action should the nurse include in the plan of care when addressing the psychosocial needs of the client?
- A. Explain to the client that open grieving is abnormal.
- B. Encourage the client to express feelings about body changes.
- C. Advise the client to seek psychological treatment after surgery.
- D. Discourage sharing with others who have had similar experiences.
Correct Answer: B
Rationale: Surgical incisions or the loss of a body part can alter a client's body image. The onset of problems coping with these changes may occur during the immediate or extended postoperative stage. Nursing interventions primarily involve providing psychological support. The nurse should encourage the client to express how he or she feels about these postoperative changes that will affect his or her life. Option 1 is an incorrect statement because open grieving is normal. Option 3 indicates disapproval, and in option 4, the nurse is giving advice.
The nurse is caring for a client with a new diagnosis of type 1 diabetes mellitus. The nurse should recognize that which teaching plan component is most important initially?
- A. Knowledge of the diabetic diet
- B. Understanding of the diagnosis
- C. Monitoring of blood glucose levels
- D. Correct technique for administering insulin
Correct Answer: B
Rationale: Before educating about a disease process, it is important that the client understands the components of the disease process. After this teaching, the actual components of diet, blood glucose testing, and insulin injections can be taught.
The nurse is caring for a client who is a victim of domestic violence. Which of the following would the nurse expect to find in the client's social history? Select all that apply.
- A. The client is under 30 years old.
- B. The client is active in a local charity.
- C. The client has a history of child abuse.
- D. The client has been in past abusive relationships.
- E. The client is employed as a college professor.
Correct Answer: C,D
Rationale: History of child abuse and past abusive relationships are risk factors for domestic violence. Age, charity involvement, or profession are not specific risk factors.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretive Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.