Nokea
Which nursing action is the highest priority during the immediate care of a rape victim?
- A. Documenting the circumstances of the rape
- B. Keeping contact with strangers to a minimum
- C. Offering the victim a choice of sedatives
- D. Providing a bath basin, gown, towel, and washcloth
Correct Answer: B
Rationale: Minimizing contact with strangers protects the victim's privacy and reduces distress, prioritizing emotional safety in the immediate aftermath.
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The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger?
- A. The client’s own private room down the hall
- B. The unit’s common television dayroom
- C. An outdoor sheltered client smoking area
- D. An out-of-the-way corner near the nursing station
Correct Answer: D
Rationale: A quiet visible corner near the station (D) aids de-escalation. Private rooms (A) and outdoor areas (C) lack visibility and the dayroom (B) is too stimulating.
Which therapeutic nursing intervention is most beneficial for a client diagnosed with post-traumatic stress disorder (PTSD)?
- A. Administering antianxiety medications
- B. Monitoring the client's physical symptoms
- C. Encouraging the client to express feelings
- D. Investigating the client's current family interactions
Correct Answer: C
Rationale: Expressing feelings helps process trauma, reducing PTSD symptoms by fostering emotional regulation and insight.
The hospitalized client has a history of weekly moderate alcohol use. Which symptoms assessed by the nurse indicate that the client may be experiencing alcohol withdrawal? Select all that apply.
- A. Agitation
- B. Hypotension
- C. Tachycardia
- D. Hallucinations
- E. Tongue tremor
Correct Answer: A, C ,D ,E
Rationale: Withdrawal causes agitation (A) tachycardia (C) hallucinations (D) and tongue tremor (E) via NMDA receptor activity. Hypotension (B) is incorrect; hypertension occurs.
The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse’s initial action?
- A. Call the mental health unit to arrange for inpatient treatment.
- B. Give medications to reverse the effects of the hallucinogenic drug.
- C. Stay with the client to protect the client from self-harm until relieved.
- D. Call hospital security so security staff is present to protect staff from injury.
Correct Answer: C
Rationale: Staying with the client (C) prevents self-harm due to altered perception. Inpatient arrangements (A) reversal drugs (B unavailable) and security (D) are secondary.
Which action is most appropriate for the nurse to take first?
- A. Remind the client that clothes are required in public.
- B. Instruct the client to put clothes on again.
- C. Explain to the residents that the client is not of sound mind.
- D. Take the client to a vacant room nearby.
Correct Answer: D
Rationale: Taking the client to a private room ensures dignity and safety, addressing the immediate need without public confrontation.