Nokea
When the rape victim arrives at the emergency department, which nursing action is best for relieving the client's anxiety?
- A. Determine the victim's last date of menstruation.
- B. Collect evidence for criminal prosecution.
- C. Assess the extent of the client's injuries.
- D. Stay with the client at all times.
Correct Answer: D
Rationale: Remaining with the victim provides emotional support and a sense of safety, directly addressing anxiety during a traumatic experience.
You may also like to solve these questions
If the nurse notes the following symptoms after the client begins taking sertraline (Zoloft), which one is most likely drug-related?
- A. Polyuria
- B. Diplopia
- C. Drooling
- D. Insomnia
Correct Answer: D
Rationale: Insomnia is a common side effect of sertraline, an SSRI, due to its activating effects on the central nervous system.
Multiple clients are being cared for on the behavioral health unit. In which circumstances should the nurse plan the therapeutic use of seclusion and/or restraints? Select all that apply.
- A. The client asks to be placed in seclusion.
- B. The client expresses the likelihood of self-injury.
- C. The staff feels the client is likely to harm others.
- D. A legally detained client is threatening to “escape.”
- E. The staff identifies seclusion as a consequence of the client’s behavior.
- F. The client’s threatening behavior is negatively affecting the therapeutic milieu.
Correct Answer: A, B ,C, D
Rationale: Seclusion/restraints are therapeutic for client request (A) self-injury risk (B) harm to others (C) or escape threats (D). Punishment (E) or milieu disruption (F) alone are not indications.
While reviewing the client's psychiatric history, the nurse would expect to note which major characteristic of bipolar disorder?
- A. Ritualistic behavior
- B. Symbolic aggressiveness
- C. Cyclic mood swings
- D. Periodic amnesia
Correct Answer: C
Rationale: Cyclic mood swings, alternating between mania and depression, are the hallmark of bipolar disorder, defining its clinical presentation.
Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?
- A. “Let’s not prejudge him. His medication should help him control his behavior.”
- B. “I will be very attentive to his behavior monitoring it for any signs of escalation.”
- C. “It may be hard but we need to appear calm and nonthreatening but alert to his behavior.”
- D. “As staff we are all trained to manage violent clients and we can handle any crisis behavior.”
Correct Answer: C
Rationale: Appearing calm and nonthreatening (C) addresses staff concerns and guides management. Prejudging (A) personal monitoring (B) or overconfidence (D) dismiss staff fears.
The client with a history of poly substance abuse is being medically detoxified in an acute care hospital. The client reported recently using alcohol oxycodone crack cocaine and marijuana. In planning for detoxification which substance for detoxification should be the nurse’s priority?
- A. Alcohol
- B. Marijuana
- C. Oxycodone
- D. Crack cocaine
Correct Answer: A
Rationale: Alcohol (A) has the most severe potentially fatal withdrawal. Marijuana (B) oxycodone (C) and cocaine (D) are less life-threatening.