A nurse is assisting in the care of a client.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Anterior fontanel closed. The anterior fontanel typically closes between 12 to 18 months of age. Closure at 4 months is premature and may indicate conditions such as craniosynostosis, which can affect skull and brain development. The provider should be notified for further evaluation.
B. Moves objects to mouth. This is an expected developmental milestone for a 4-month-old infant. At this age, infants begin to grasp objects and bring them to their mouths as part of their sensory exploration.
C. Rolls from back to abdomen. Most infants begin rolling from back to abdomen around 5 to 6 months. If a 4-month-old achieves this milestone early, it is not necessarily concerning but rather an indication of advanced motor development.
D. Posterior fontanel closed. The posterior fontanel typically closes between 6 to 8 weeks of age, so closure by 4 months is expected and does not require provider notification.
Correct Answer is A
Explanation
A. An advanced practice nurse, such as a nurse practitioner or clinical nurse specialist, has the training to assess medication interactions and adjust prescriptions if necessary. They can evaluate the client's medications, consider potential adverse effects, and collaborate with the prescribing provider. Consulting an advanced practice nurse ensures safe and effective medication management.
B. A psychologist focuses on mental health assessment and therapy but does not prescribe or manage medications. They may help clients cope with medication-related concerns, but they lack the authority to assess or modify prescriptions. Medication-related inquiries should be directed to a medical provider or pharmacist.
C. A social worker assists clients with psychosocial needs, financial concerns, and community resources but does not have the expertise to evaluate medication interactions. They can provide support for medication access or adherence issues but not clinical medication guidance. Medication safety requires consultation with a qualified medical professional.
D. A patient care technician provides basic client care, such as vital sign monitoring and assisting with activities of daily living. They do not have the training to assess medication interactions or provide pharmacological advice. Medication concerns should be referred to a licensed healthcare provider.
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