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 D

Explanation

A. "You should only drink 2 cups of coffee per day." While limiting coffee intake can be beneficial for some individuals with GERD, the recommendation should focus on overall caffeine intake rather than a specific amount. Caffeine can relax the lower esophageal sphincter and exacerbate symptoms, so some individuals may need to eliminate it entirely.
B. "You should eat three large meals and two snacks per day." Eating large meals can increase intra-abdominal pressure and exacerbate GERD symptoms. Instead, clients should be encouraged to eat smaller, more frequent meals throughout the day to help minimize reflux.
C. "You should lay down for 1 hour following a meal." Laying down after eating can increase the likelihood of reflux and heartburn. Clients should be advised to remain upright for at least 2 to 3 hours after meals to help prevent symptoms.
D. "You should elevate the head of the bed while sleeping." Elevating the head of the bed is a recommended practice for clients with GERD. This position can help prevent nighttime reflux by allowing gravity to keep stomach acid from rising into the esophagus, thereby reducing symptoms and improving sleep quality.

A. Cottage cheese B. Bran muffin C. Tomato juice D. Puffed rice cereal

Correct Answer is B

Explanation

A. Cottage cheese: Cottage cheese is low in fiber and does not promote bowel regularity. A diet high in fiber is recommended to help soften stool and stimulate peristalsis, which is necessary for relieving constipation.
B. Bran muffin: Bran is an excellent source of dietary fiber, which adds bulk to stool and facilitates easier bowel movements. High-fiber foods, such as whole grains, fruits, and vegetables, are essential in managing constipation effectively.
C. Tomato juice: While tomato juice contains some nutrients, it is not a significant source of fiber. Increasing fiber intake is more beneficial for constipation than consuming low-fiber liquids. However, adequate hydration is still important in preventing hard stools.
D. Puffed rice cereal: Puffed rice cereal is typically refined and low in fiber, making it a poor choice for relieving constipation. Whole grains, such as bran, oatmeal, or whole wheat products, are more effective in promoting bowel regularity.

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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.

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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.