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 A
Explanation
Explanation:
A nasal cannula is a device used to deliver supplemental oxygen to a client. It consists of two prongs that are inserted into the client's nostrils and connected to an oxygen source. The nasal cannula is commonly used for low-flow oxygen delivery at a rate of 1 to 2 liters per minute (L/min).
The other options mentioned are not necessary supplies for the client upon discharge:
B- Petroleum jelly is not directly related to oxygen therapy and is not a required supply for the client. It is a common topical ointment used for various purposes such as moisturizing the skin or protecting the lips, but it is not specifically needed for oxygen administration.
C- An oxygen mask is an alternative device for oxygen delivery but is not typically used at a flow rate of 1 to 2 L/min. Oxygen masks are usually employed for higher flow rates or in specific clinical situations that require a different oxygen delivery method.
D- A reservoir bag is a component of some oxygen delivery systems, such as a non-rebreather mask or a bag-valve-mask device. However, at a flow rate of 1 to 2 L/min, a reservoir bag is not typically used. It is more commonly utilized in situations where higher oxygen concentrations or higher flow rates are required.
Correct Answer is A
Explanation
A- "My partner will use condoms with spermicides": Using condoms with spermicides can increase the effectiveness of contraception by combining a barrier method with a chemical method to kill sperm.
B.Using two condoms simultaneously (also known as "double bagging") is not recommended because the friction between them can increase the chance of them tearing.
C- "I will be able to remove my contraceptive sponge immediately after intercourse": The contraceptive sponge is a barrier method that is inserted into the vagina before intercourse. It should be left in place for at least 6 hours after intercourse to ensure effectiveness. Removing it immediately after intercourse would decrease its contraceptive effectiveness.
D- "My partner and I will use petroleum jelly with latex condoms": Petroleum jelly, along with other oil-based lubricants, should not be used with latex condoms. Oil-based substances can degrade latex, making the condom more prone to breakage. Water-based lubricants are recommended for use with latex condoms to ensure their integrity and effectiveness.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
