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
Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.
Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.
Prothrombin time (PT) is a test used to evaluate the clotting ability of the blood and is not directly related to thyroid function or levothyroxine therapy.
Arterial blood gases (ABGs) are used to assess oxygen and carbon dioxide levels in the blood and evaluate acid-base balance. ABGs are not specifically related to thyroid function or levothyroxine therapy.
Correct Answer is C
Explanation
Insomnia refers to the difficulty in falling asleep or staying asleep, leading to sleep disturbances. It is a frequently reported symptom during the initial phase of nicotine withdrawal.
While weight loss can be associated with smoking cessation due to changes in metabolism, it is not a direct manifestation of nicotine withdrawal. Similarly, diarrhea is not a commonly reported symptom of nicotine withdrawal.
Diaphoresis, which refers to excessive sweating, can occur in some individuals during nicotine withdrawal, but it is not as commonly observed as insomnia. It is worth noting that different individuals may experience varying symptoms during nicotine withdrawal, and the intensity and duration of these symptoms can also differ.
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