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 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.

A. Coil the tubing on the bed above the collection bag. B. Instruct the client to hold the drainage bag at waist height when ambulating. C. Secure the tubing with adhesive tape to the lower abdomen. D. Collect a sterile specimen from the urinary drainage bag.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information?

Correct Answer is B

Explanation

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is ["A","B","C"]

Explanation

A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should the nurse make?

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse is helping to place a client into the prone position. The nurse should use a small pillow to relieve pressure from which of the following areas of the client's body?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?