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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Free Nursing Study Resources

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

Explanation

A.The client's complaint of upper chest discomfort and coughing up thick clear sputum suggests a potential respiratory issue. Checking oxygen saturation is crucial to assess for possible respiratory distress or hypoxia.

B.Tremors are a chronic symptom associated with Parkinson's disease in this client. While monitoring tremors is important for assessing Parkinson's disease management, they are not an acute issue requiring immediate follow-up in this scenario.

C.Coughing up thick clear sputum and upper chest discomfort indicate potential respiratory distress or infection. Monitoring the respiratory rate helps assess the severity of respiratory distress or compromise.

D.Heart rate is a vital sign that can indicate cardiovascular status and response to the client's reported symptoms of feeling bad. Elevated heart rate may indicate stress, pain, or cardiac involvement.

E.The client is reported as alert and oriented to self. While changes in level of consciousness are always important to monitor, the client's current alert and oriented state suggests no immediate acute change.

F.Chronic health conditions such as Parkinson's disease and anxiety are part of the client's history but are not acute findings that require immediate follow-up compared to the acute symptoms of upper chest discomfort and respiratory distress reported.

A. Reinforce with the client to sleep on the side of the access site. B. Obtain the client's blood pressure in either arm. C. Encourage the client to increase fluid intake. D. Obtain the client's weight.

Correct Answer is D

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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?

Correct Answer is D

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