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The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse's next action should be to:
- A. do nothing; the client has the right to refuse treatment.
- B. report the incident to the police.
- C. arrange an appointment with the client's next of kin.
- D. educate the client about available services.
Correct Answer: D
Rationale: Although clients do have the right to refuse treatment, the nurse should remain nonjudgmental and inform the client of available services. Frequently elders are not aware of existing programs.
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A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: Asking the client to describe the hallucinations validates their experience and provides insight into their condition, aiding therapeutic communication. Touching may be intrusive, leaving them alone is non-therapeutic, and denying the voices dismisses their reality.
A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to:
- A. identify all psychosocial problems.
- B. eliminate the client's enticing behaviors.
- C. resolve feelings of trauma and fear.
- D. verbalize feeling about the event.
Correct Answer: D
Rationale: A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological problems are identified, the nurse might make referrals for treatment.
Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of:
- A. 30 mmHg systolic and/or 15 mmHg diastolic.
- B. 40 mmHg systolic and/or 20 mmHg diastolic.
- C. 10 mmHg systolic and/or 5 mmHg diastolic.
- D. 20 mmHg systolic and/or 20 mmHg diastolic.
Correct Answer: A
Rationale: These are the accepted parameters for mild PIH. Mild preclampsia includes an increase in systolic blood pressure higher than 30 mmHg or an increase in diastolic blood pressure higher than 15 mmHg, noted on two readings taken 6 hours apart (or 140/90).
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. Inform the client that because she is underage, she is at fault for attending a party where alcohol was served
- B. Ask the client if anyone witnessed the event because the client was intoxicated and might not remember correctly
- C. Inform the client that it was not her fault, and support the client through the physical examination
- D. Question whether the woman had consensual sex and now just feels guilty
Correct Answer: C
Rationale: Supporting the client and affirming that the rape was not her fault is critical, as acquaintance rape is serious and not negated by alcohol consumption.
A client admitted to the medical nursing unit has classic symptoms of tuberculosis (TB) and tests positive on the purified protein derivative (PPD) skin test. Several months later, the nurse who cared for the client also tests positive on an annual TB skin test for work. The most likely course of treatment if the chest X-ray (CXR) is negative is to:
- A. repeat a TB skin test in six months.
- B. treat the nurse with an anti-infective agent for six months.
- C. monitor for signs and symptoms within the next year.
- D. follow up in one year at the next annual physical with CXR only.
Correct Answer: B
Rationale: Exposure with a positive TB skin test usually requires six months of prophylactic treatment unless contraindicated.