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
Do you have any plan for harming yourself?
When a client expresses suicidal ideations, the nurse's priority is to assess whether the client has a specific plan for harming themselves. This question helps determine the level of immediate risk and guides the nurse's actions in providing appropriate interventions and ensuring the client's safety.:
Can you tell me about the stresses in your life? In (option B) is incorrect. While understanding the client's stressors is important in assessing their overall mental health, it may not be the priority question in this situation. The immediate concern is to assess the presence of a specific plan for self-harm.
Do you have someone to discuss your feelings with? In (option C) is incorrect. Having someone to talk to about feelings can be beneficial for the client, but it is not the priority question in this situation. The primary focus is to assess the client's immediate risk and take appropriate actions to ensure their safety.
Has anyone in your family ever died by suicide? In (option D) is incorrect. Family history of suicide can be a risk factor for suicidal ideation, but it is not the priority question in this scenario. Assessing the client's current risk and immediate plan for self-harm is more crucial to determine the necessary interventions.
Correct Answer is ["A","C","E"]
Explanation
Since the client's respiratory rate is labored and there are abnormal breath sounds (crackles and wheezes), it is important to assess their oxygen saturation level. This finding can help determine the adequacy of their oxygenation and whether intervention is needed.
The client's labored respirations, along with the presence of abnormal breath sounds, indicate potential respiratory distress. Assessing their respiratory rate is crucial to determine the severity of the respiratory compromise and the need for immediate intervention.
The nurse's note mentions that the client is restless and not following commands. This change in the level of consciousness may indicate a decline in neurological status and should be promptly evaluated.
The other options listed (tremors in hands, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.
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