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 B
Explanation
Valid and reliable health information sources should provide references or citations to support the information they present. This demonstrates that the information is based on evidence and has been reviewed by experts in the field. It allows readers to verify the accuracy and reliability of the information by referring to the cited sources.
The author's name listed without credentials does not provide information about the author's expertise or qualifications. It is important to assess the author's credentials and expertise to determine their credibility.
The website URL is listed as .com does not provide information about the accuracy or reliability of the content. Different types of websites, such as .org or .gov, can also contain credible health information.
The website being last updated 3 years ago raises concerns about the currency and relevance of the information. Health information can quickly evolve, and it is important to access up-to-date resources.
Correct Answer is ["A","B","C"]
Explanation
Coiling the tubing on the bed above the collection bag helps to prevent the backflow of urine and maintains the integrity of the drainage system. This positioning allows for proper gravity drainage and prevents urine from pooling in the tubing.
Instructing the client to hold the drainage bag at waist height helps to ensure proper urine flow and prevent tension or pulling on the catheter. This positioning also prevents the bag from dragging on the floor, reducing the risk of contamination or accidental disconnection.
Securing the tubing with adhesive tape to the lower abdomen helps to prevent accidental pulling or dislodgment of the catheter. This ensures that the catheter remains in place and minimizes the risk of trauma or discomfort for the client.
If a sterile urine specimen is required, it should be collected using a separate sterile container and not directly from the urinary drainage bag. The drainage bag may contain contaminants or non-sterile elements, so a separate specimen collection method should be employed to ensure accuracy and prevent contamination.
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