A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?

"I can encourage my child to think about what they did that allowed this event to happen."

"I should encourage my child to focus solely on the future."

"I will have to do all I can to monitor my child's relationships."

"I anticipate that my child will feel some self-blame."

Answer and Explanation

The Correct Answer is D

A.   This statement suggests a potential for victim-blaming or placing responsibility on the adolescent for the assault. It does not reflect a positive support system because it may contribute to feelings of guilt and shame in the adolescent. Victims of sexual assault should not be made to feel responsible for the actions of the perpetrator.
B.   While encouraging the adolescent to focus on the future can be positive, solely focusing on the future without acknowledging or processing the trauma of the assault may invalidate the adolescent's current feelings and experiences. A supportive approach involves acknowledging and validating the adolescent's emotions and experiences, both past and present.
C.   This statement may come from a place of concern for the adolescent's safety and well-being, which is understandable. However, it can also indicate a lack of trust or an overprotective stance that may not fully empower the adolescent to regain a sense of control over their life and decisions.
D.   This statement demonstrates an understanding of common reactions and emotions experienced by individuals who have been sexually assaulted. Acknowledging that the adolescent may feel self-blame can be a way to open up discussions about these feelings and reassure the adolescent that they are not at fault. It shows empathy and readiness to support the adolescent emotionally.

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Correct Answer is A

Explanation

A. This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B. Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C. Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D. The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

A. Bradycardia B. Drowsiness C. Double vision D. Hypertension

Correct Answer is D

Explanation

A. Bradycardia (slow heart rate) is not typically associated with alcohol withdrawal. Instead, tachycardia (rapid heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the autonomic nervous system.
B. Drowsiness is not a common symptom of alcohol withdrawal. Instead, individuals may experience insomnia or disturbed sleep patterns as part of withdrawal symptoms.
C. Double vision (diplopia) is not a typical finding in alcohol withdrawal.
D. When a person stops or significantly decreases their alcohol intake after long-term use, the body can react with symptoms like increased blood pressure.

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A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who reports drinking alcoholic beverages daily but has not consumed alcohol in the last 24 hr. Which of the following findings should the nurse identify as a manifestation of alcohol withdrawal?

Correct Answer is D

Explanation

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