A nurse is assisting in the care of a client. Nurses' Notes

2000:

The client presents to the emergency department and states, "I have been assaulted." The client was immediately placed in a treatment

room. 2015:

"The client states they were out with friends this evening and had "a little too much to drink." The client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." The client reports a history of depression. The client is a full-time college student who lives with roommates. The client admits to drinking socially but denies illicit drug use and tobacco use.

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

Contact children and youth services.

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

Request a consult for case management.

Maintain a safe and private environment for the client.

Administer sexually transmitted infection prophylaxis.

Provide resources for local support services.

Answer and Explanation

Correct Answer : C,D,E,F

Case management can be beneficial in situations involving assault to help coordinate and provide ongoing support and resources for the client. This intervention is appropriate in this scenario.

Ensuring a safe and private environment is crucial to protect the client's confidentiality and provide a supportive atmosphere during this difficult time. This intervention is necessary.

Since the client reports being assaulted and has sore genitals, it is important to consider the risk of sexually transmitted infections (STIs). Administering STI prophylaxis can help prevent potential infections.

The client may benefit from additional support services such as counseling or support groups. Providing resources for local support services can help the client access the necessary help and support they need.

Contacting children and youth services is not applicable in this scenario as the client is a full-time college student and not a child or youth.

While the client mentioned drinking, it is not explicitly stated that they have an alcohol addiction or problem. Therefore, providing resources for Alcoholics Anonymous may not be the most appropriate intervention at this time.

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Correct Answer is C

Explanation

The shoulder harnesses of the car seat should be adjusted to fit the infant properly. The straps should be positioned at or below the level of the infant's shoulders to ensure a secure fit and proper restraint.

Infants should always be placed in a rear-facing car seat in the back seat of the vehicle. If the car seat is placed in the front seat, the airbag should be turned off to prevent potential harm to the infant in case of airbag deployment.

Do not put a small cushion under the newborn's head for support: It is important to follow the manufacturer's guidelines for the specific car seat being used. Additional cushions or supports should not be added to the car seat as they can interfere with the proper fit and safety of the seat. The infant's head should be supported by the car seat itself.

Infants should be placed in a rear-facing car seat at a reclined angle of approximately 45 degrees. This helps to keep the infant's airway open and provides proper support for their head and neck.

A. Giving change-of-shift report to a nurse outside the client's room B. Discussing a client's prognosis with an assistive personnel who is caring for the client C. Writing a client's diagnosis on the message board in the client's room D. Discarding worksheets containing client information in a wastebasket

Correct Answer is A

Explanation

When providing a change-of-shift report, it is important to do so in a private and secure area away from public spaces. Sharing client information outside the client's room helps maintain confidentiality and prevents unauthorized individuals from overhearing sensitive information. Discussions about a client's prognosis should be limited to the appropriate healthcare professionals involved in the client's care. Sharing this information with an assistive personnel who is not directly involved in the client's care breaches confidentiality.

Displaying a client's diagnosis on a message board in a public area breaches confidentiality. It is essential to respect and protect a client's privacy by avoiding the unnecessary disclosure of sensitive information.

Proper disposal of documents containing client information is crucial to maintain confidentiality. Discarding worksheets with client information in a wastebasket without ensuring they are securely destroyed or shredded poses a risk of unauthorized access to sensitive information.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

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A nurse is providing a change-of-shift report for a client. Which of the following information should the nurse include in the report?

A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?