A nurse is assisting in the care of a client.

Exhibits

Which of the following interventions should the nurse plan to implement? Select all that apply.

Contact children and youth services.

Administer sexually transmitted infection prophylaxis.

Provide resources to the client for the local Alcoholics Anonymous chapter.

Maintain a safe and private environment for the client.

Request a consult for case management.

Provide resources for local support services.

Answer and Explanation

Correct Answer : B,D,E,F

A. Contact children and youth services. There is no indication that the client is a minor. Mandatory reporting to child protective services applies to minors, but in the case of an adult client, reporting sexual assault is the client’s decision unless required by law (such as in cases involving incapacitated individuals or threats to public safety).
B. Administer sexually transmitted infection prophylaxis. Clients who have experienced sexual assault should be offered prophylactic treatment for sexually transmitted infections (STIs), including chlamydia, gonorrhea, and trichomoniasis, in accordance with CDC guidelines. Post-exposure prophylaxis for HIV may also be considered based on risk factors.
C. Provide resources to the client for the local Alcoholics Anonymous chapter. The client reports social drinking but has not indicated problematic alcohol use or a desire for treatment. Providing unsolicited resources for Alcoholics Anonymous may not be appropriate in this situation.
D. Maintain a safe and private environment for the client. Ensuring privacy and a safe space is essential for clients who have experienced trauma. The nurse should provide emotional support, minimize interruptions, and allow the client to make decisions regarding care.
E. Request a consult for case management. Case management services can assist with legal considerations, follow-up care, counseling referrals, and safety planning. The nurse should initiate a referral to support the client’s needs.
F. Provide resources for local support services. Sexual assault survivors should receive information about crisis hotlines, advocacy groups, counseling services, and other community resources that can offer emotional and legal support.

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Correct Answer is A

Explanation

A. Initiate droplet precautions. Respiratory syncytial virus (RSV) is primarily transmitted through respiratory secretions, requiring contact and droplet precautions to prevent the spread. Isolation measures, including wearing masks and gowns, help protect healthcare workers and other patients.
B. Administer fluconazole to the preschooler. Fluconazole is an antifungal medication, which is not effective against RSV, a viral infection. Treatment for RSV is mainly supportive, focusing on airway management, hydration, and oxygen therapy as needed.
C. Monitor the preschooler's urine for protein. Proteinuria is associated with kidney conditions such as nephrotic syndrome, not RSV. RSV primarily affects the respiratory system, causing bronchiolitis and increased mucus production rather than kidney involvement.
D. Request an x-ray of the preschooler's neck. A neck x-ray is typically used to evaluate airway obstruction from conditions like epiglottitis. RSV affects the lower respiratory tract, leading to bronchiolitis, and does not usually require imaging unless complications arise.

A. Offer the client several choices at mealtimes. B. Alternate daily caregivers. C. Remind the client of the day and time often. D. Avoid discussing the client's fears.

Correct Answer is C

Explanation

A. Offer the client several choices at mealtimes. Clients with delirium often experience confusion and difficulty processing information. Providing too many choices can increase anxiety and agitation. Instead, offering simple and limited options helps reduce cognitive overload.
B. Alternate daily caregivers. Consistency in caregivers is important for clients with delirium to minimize confusion and distress. Frequent changes in caregivers can contribute to disorientation and make it more difficult for the client to feel secure.
C. Remind the client of the day and time often. Delirium is characterized by fluctuating levels of consciousness and confusion. Frequent orientation to time, place, and situation helps reduce anxiety and supports cognitive function. Using clocks, calendars, and familiar objects in the environment can reinforce orientation.
D. Avoid discussing the client's fears. Clients with delirium may have distressing thoughts or fears that should be acknowledged and addressed. Providing reassurance and a calm, supportive environment can help alleviate anxiety and improve the client's well-being.

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A nurse is assisting in the care of a client. Exhibits Which of the following interventions should the nurse plan to implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

Exhibits Complete the following sentence by using the list of options The nurse should first address the client’s dropdownfollowed by the client’sdropdown

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A nurse is assisting in the care of a client.

Exhibits

Which of the following interventions should the nurse plan to implement? Select all that apply.