A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?

Conduct a pregnancy test.

Request a mental health consultation for the client.

Offer prophylactic medication to prevent STIS.

Provide a trained advocate to stay with the client.

Answer and Explanation

The Correct Answer is D

The nurse should provide a trained advocate to stay with the client, as this can help reduce the psychological trauma and provide emotional support and information to the client. The other options are also important, but they can be done later or after obtaining the client's consent.

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Correct Answer is D

Explanation

A low platelet count (thrombocytopenia) can indicate bleeding disorders, infections, or adverse effects of medications. Clonazepam can cause thrombocytopenia as a rare but serious side effect. The nurse should report this finding to the provider as it may indicate a need to discontinue or adjust the medication.

A. WBC count 13,000/mm B. Neuropathy C. BUN 16 mg/dL D. Hypertension

Correct Answer is A

Explanation

A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.

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A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory results should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

Correct Answer is A

Explanation

A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?

A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home." Which of the following recommendations should the nurse make to address the client's social isolation?

A nurse is caring for a client who has been taking valproic acid. Which of the following is an expected outcome of the medication?

A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?