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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Free Nursing Study Resources

Correct Answer is B

Explanation

I can remove my security band to give it to a family member.

In healthcare facilities, security measures are implemented to ensure the safety and identification of patients and newborns. One common security measure is the use of identification bands for both the mother and the baby. These bands typically have matching identification numbers or barcodes that help staff members verify the identity of the individuals and ensure they are correctly paired.

Option A is incorrect because removing the security band and giving it to a family member would compromise the system's security and potentially lead to confusion or incorrect identification.

Option C is incorrect because taking the baby to the lobby to visit family can increase the risk of unauthorized individuals gaining access to the baby or potentially interfering with the security measures in place.

Option D is incorrect because carrying the baby to the nursery without following the facility's security protocols can also compromise the identification and safety measures.

The best response indicating an understanding of the teaching is option B, as it recognizes the importance of having an identification band that matches the one worn by the baby. This indicates awareness of the security measures in place and the need to ensure accurate identification and safety.

A. Apply the restraint under the client's clothes. B. Tie the restraint to the railing of the client's bed. C. Place the client in a sitting position. D. Ensure the restraint is placed across the client's chest.

Correct Answer is C

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

Correct Answer is C

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

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

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-colonic seizure. Which of the following actions should the nurse take?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?