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

Let me show you how to swaddle and cuddle him, then you try.

The appropriate response for the nurse in this situation is to provide support and education to the new mother. Option B, "Let me show you how to swaddle and cuddle him, then you try," demonstrates a helpful and empowering approach.

I'll take him back to the nursery, so you can get some rest in (option A) is incorrect. This response dismisses the mother's concerns and suggests removing the baby from her care without addressing her need for guidance and support. It is important to encourage and assist the mother in learning how to care for her newborn rather than taking over the responsibility.

If I turn him on his side, maybe he'll go back to sleep in (option C) is incorrect. This response suggests a specific action without addressing the underlying concerns of the mother. It is important to provide guidance and reassurance rather than suggesting potential solutions without understanding the cause of the baby's crying.

Babies need to cry soon after they are born to develop their lungs in (option D) is incorrect. This response is not relevant to the mother's concerns and does not address her feelings of inadequacy. It is important to provide support and guidance in caring for the newborn rather than providing unrelated information.

A. Contact children and youth services. B. Provide resources to the client for the local Alcoholics Anonymous chapter. C. Request a consult for case management. D. Maintain a safe and private environment for the client. E. Administer sexually transmitted infection prophylaxis. F. Provide resources for local support services.

Correct Answer is ["C","D","E","F"]

Explanation

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.

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.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

Correct Answer is B

Explanation

Correct Answer is ["C","D","E","F"]

Explanation

A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

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