Nokea
When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?
- A. Do not bathe or shower.
- B. Make a sketch of the rapist.
- C. Write down what happened.
- D. Call a 911 operator.
Correct Answer: A
Rationale: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.
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The indigent client with both emotional and physical diagnoses has just attended a discharge planning session with the nurse. Which client behavior shows the greatest commitment to the client’s self-management?
- A. Correctly stating the medications prescribed and the administration schedule
- B. Asking to stay with a relative until an affordable place to live can be found
- C. Researching the names of and calling contact people at local support centers
- D. Promising the nurse to keep the scheduled follow-up appointments at the clinic
Correct Answer: C
Rationale: Calling support centers (C) shows proactive engagement. Stating medications (A) seeking housing (B) and promising appointments (D) are less indicative of commitment.
The nurse observes that the client diagnosed with intermittent explosive disorder is becoming aggressive and that lorazepam was prescribed. The client is now exhibiting a tense posture a clenched fist and a defiant affect. Prioritize the nurse’s actions to de-escalate the client’s aggression.
- A. Call other staff for assistance.
- B. Attempt to talk the client down.
- C. Apply wrist restraints.
- D. Offer client choice of taking medication voluntarily.
- E. Provide alternate use of physical energy such as suggesting punching a pillow.
Correct Answer: B ,E ,D ,A, C
Rationale: Talk down (B) builds trust offering physical outlets (E) releases tension medication choice (D) calms staff assistance (A) ensures safety and restraints (C) are last resort for harm prevention.
Which action by the client is most suggestive of denial about the illness?
- A. The client conceals the information from family members.
- B. The client avoids contact with homosexual friends.
- C. The client responds to the former group of the nurse.
- D. The client has intercourse without using condoms.
Correct Answer: D
Rationale: Engaging in unprotected intercourse indicates denial of the HIV diagnosis, as it disregards the risk of transmission and personal health implications.
The older disheveled client is admitted to the ED with hypertension severe dehydration and malnourishment. During the admission interview the daughter notes that she and her husband who is temporarily out of work have been living with the client. Which nursing action is most important?
- A. Report the suspected elder abuse to Adult Health Protective Services.
- B. Ask additional questions of the client in private without the family present.
- C. Ask the daughter whether her father has been eating and taking his medication.
- D. Call the resource hotline to ask whether abuse and neglect should be considered.
Correct Answer: B
Rationale: Private questioning (B) elicits abuse/neglect details. Reporting (A) needs more evidence asking the daughter (C) is less direct and calling a hotline (D) is secondary.
The nurse correctly explains to the nursing assistant that this is an example of a client using which coping mechanism?
- A. Introjection
- B. Projection
- C. Compensation
- D. Displacement
Correct Answer: D
Rationale: Displacement involves redirecting emotions, such as anger from a spouse, onto a safer target like the nursing assistant, as seen in the client's behavior.