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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.
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The 28-year-old is being seen in the ED with injuries after being assaulted by her live-in boyfriend. The client acknowledges that this is not the first time that she has been assaulted and that she is afraid. Which client action indicates that an outcome for the client has been achieved?
- A. Elects to return to her boyfriend to make amends
- B. Accepts arrangements made with a women’s shelter
- C. Verbalizes plans for staying at the hospital overnight
- D. Asks the nurse to report the assault to Adult Health Protective Services
Correct Answer: B
Rationale: Accepting shelter arrangements (B) ensures safety a key outcome. Returning to the abuser (A) staying overnight (C) or requesting reporting (D nurse’s duty) are not optimal.
When the older client with Alzheimer's disease is confused about how to use a fork, which nursing action is best for prolonging an ability to maintain self-care?
- A. Ask the physician to order a liquid diet.
- B. Position the client to promote mimicking other clients.
- C. See the client first so there is sufficient time to eat.
- D. Seat the client alone so no one will see any mess that occurs.
Correct Answer: B
Rationale: Mimicking others leverages social cues, encouraging independent eating and prolonging self-care abilities.
When interacting with a client experiencing a panic attack, which technique by the nurse is most likely to help reduce the client's anxiety level?
- A. Stand less than an arm's length away.
- B. State that everything is going to be okay.
- C. Instruct the client to take shallow breaths.
- D. Explain all actions and procedures.
Correct Answer: D
Rationale: Explaining actions provides predictability, reducing anxiety by enhancing the client's sense of control during a panic attack.
The nurse is preparing to administer thiamine (vitamin B1) to the client receiving treatment for alcohol dependence. Which statement best describes the rationale for the use of thiamine?
- A. Thiamine improves the absorption of other essential vitamins and folic acid.
- B. Thiamine helps to reverse the malnutrition often associated with alcohol abuse.
- C. Thiamine reduces the risk of seizures occurring during withdrawal from alcohol.
- D. Thiamine prevents neuropathy and confusion associated with chronic alcohol use.
Correct Answer: D
Rationale: Thiamine prevents neuropathy and confusion from deficiency (D). It doesn’t aid absorption (A) malnutrition reversal (B) is secondary and seizures (C) need anticonvulsants.
If the client is typical of others of similar age, the nurse can anticipate the client as having which age-related problems? Select all that apply.
- A. Becoming cynical
- B. Losing patience
- C. Developing hostility
- D. Having periods of regret
- E. Experiencing episodes of depression
Correct Answer: D,E
Rationale: Regret and depression are common in late adulthood as individuals reflect on life, per Erikson's integrity vs. despair stage.