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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Preschoolers often think in magical or egocentric ways and may believe that death is a punishment for something they or others did wrong. This belief reflects their developmental stage, where they may not understand the abstract concept of death and may interpret it in relation to their own actions or behaviors.
B.Preschoolers may have difficulty understanding the permanence of death. They might think that the deceased parent will wake up eventually or return, as their grasp on the concept of permanence is not fully developed.
C.While preschoolers may be curious about many things, including new experiences, their understanding of a funeral and its significance may be limited. They might not fully grasp the meaning behind the service but may ask questions out of curiosity.
D.Preschoolers typically do not have a concrete understanding of the concept of death or the inevitability of death for everyone. Their understanding is usually very limited and concrete, so this would not be consistent with their developmental stage.
Correct Answer is A
Explanation
Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. When providing discharge teaching to the caregiver of a client with dependent personality disorder, it is important to promote the client's independence and self-empowerment. Encouraging the client to be assertive is an appropriate instruction because it promotes the development of self-advocacy skills and assertiveness, which can help the client gain confidence and reduce dependency on others.
limiting the client's social interactions in (option B) is incorrect because it, would not be an appropriate instruction. Restricting social interactions may further reinforce the client's dependency and hinder their ability to develop social skills and relationships.
maintaining a verbal no-harm contract with the client in (option C) is incorrect because it, is not specifically related to the management of dependent personality disorder. No-harm contracts are more commonly used in the context of managing self-harm or suicidal ideation, which may or may not be present in individuals with dependent personality disorder.
assuming responsibility for making the client's decisions in (option D) is incorrect because it, would further enable the client's dependency and undermine their autonomy. It is important to encourage the client to make their own decisions and take responsibility for their actions, within their capabilities.
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