A nurse is assisting in the care of a client. Nurses' Notes 2000:
Client presents to emergency department and states, "I have been assaulted." Client was immediately placed in a treatment room.
2015:
"Client states they were out with friends this evening and had "a little too much to drink." 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." Client reports history of depression. Client is a full-time college student who lives with roommates. 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 D
Explanation
The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.
Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.
Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.
Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.
It's important to promote mobility and independence for the client while ensuring their safety.
Correct Answer is A
Explanation
Explanation:
Yogurt can be beneficial for individuals with irritable bowel syndrome (IBS) because it contains probiotics, which are live bacteria that can help promote a healthy balance of gut bacteria.
Probiotics have been shown to potentially alleviate symptoms of IBS, such as bloating, gas, and abdominal discomfort. Additionally, yogurt is a good source of calcium and protein.
B- On the other hand, "Honey" is not specifically recommended for individuals with IBS as it can be a source of fermentable carbohydrates and may contribute to symptoms such as bloating and gas in some individuals.
C- "Watermelon" is generally well-tolerated by most people and can be included in the diet of individuals with IBS, as it is low in FODMAPs (fermentable carbohydrates that can trigger IBS symptoms in some individuals).
D- "Ice cream" is not typically recommended for individuals with IBS, as it often contains high amounts of fat and lactose, which can aggravate symptoms in some individuals. However, this can vary depending on the individual's tolerance to dairy and fat.
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