A nurse is caring for a client following reported physical abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take?
Display disapproval toward the perpetrator.
Probe the client to offer a factual account of the abuse.
Be direct and honest when communicating with the client.
Invite a family member to be present for the nursing history.
The Correct Answer is C
"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.
Option A: "Display disapproval toward the perpetrator" - Not appropriate for the clinical setting
Option B: "Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting
Option D: "Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should recommend establishing a reward system for positive behavior when contributing to the plan of care for a child with an autism spectrum disorder. Reward systems can be particularly effective for children with autism spectrum disorder, as they respond well to structured routines and consistency.
Choice A, assuring that the child has a large variety of caregivers, is not recommended, as children with autism spectrum disorder can be particularly sensitive to changes in routine and caregivers. Providing a flexible schedule to adjust to the child's interests,
choice C may be appropriate in some cases, but a structured routine can be even more beneficial. Allowing for imaginative play with peers without supervision, choice D, may not be safe or effective in all situations. It is important for the nurse to work with the child, their family, and other healthcare professionals to develop an individualized plan of care that meets the child's specific needs and goals.
Correct Answer is C
Explanation
Constipation. Constipation is a common symptom of anorexia nervosa, as it can result from severe food restriction, dehydration, electrolyte imbalance, or laxative abuse. People with anorexia may also experience abdominal pain and bloating due to constipation.
Choice A. Hyperkalemia. Hyperkalemia is a condition of high potassium levels in the blood. It is not a typical symptom of anorexia, as people with anorexia tend to have low potassium levels due to vomiting, diuretic use, or inadequate intake.
Hyperkalemia can cause irregular heart rhythms, muscle weakness, and paralysis.
Choice B. Tachycardia. Tachycardia is a condition of fast heart rate. It is not a common symptom of anorexia, as people with anorexia tend to have bradycardia, which is a slow heart rate. Bradycardia can result from starvation, dehydration, or electrolyte imbalance and can lead to cardiac arrest. Tachycardia can occur in some cases of anorexia due to dehydration, anxiety or refeeding syndrome.
Choice D. Metrorrhagia. Metrorrhagia is a condition of irregular or excessive bleeding between menstrual periods. It is not a usual symptom of anorexia, as people with anorexia tend to have amenorrhea, which is the absence of
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