A nurse is speaking with a client who experienced physical assault. Which of the following actions should the nurse take?

Allow the client to control the conversation.

Ask the client a series of questions about who assaulted them.

Insist the client report the incident.

Touch the client for reassurance.

Answer and Explanation

The Correct Answer is A

A. Allowing the client to control the conversation empowers them to share their experience at their own pace and in their own way. This approach fosters trust and facilitates open communication between the nurse and the client.

B. While gathering relevant information about the assault may be necessary for documentation and reporting purposes, it's important to approach the topic with sensitivity and respect for the client's emotional well-being.

C. Pressuring the client to report the incident against their will can further traumatize them and undermine their sense of control. Reporting the assault is a personal decision that should be made by the client based on their individual circumstances and preferences.

D. Touch can be a powerful form of nonverbal communication that conveys empathy, support, and reassurance. However, it's important to obtain the client's consent before initiating any form of physical contact, especially considering the sensitive nature of the situation.

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Correct Answer is A

Explanation

A. A serum lithium level of 1.6 mEq/L is above the therapeutic range, indicating lithium toxicity. Manifestations of lithium toxicity can include neurological symptoms such as blurred vision and jerking motor movements. Other symptoms may include nausea, vomiting, diarrhea, tremors, confusion, drowsiness, and muscle weakness.

B. Fever and fluctuating blood pressure are not typical manifestations of lithium toxicity.

C GI discomfort, such as nausea, vomiting, and diarrhea, is a common symptom of lithium toxicity. Poor coordination, along with tremors and muscle weakness, can also occur due to the effects of lithium on the central nervous system.

D. Lip smacking and tongue thrusting are repetitive and involuntary movements associated with certain types of seizures or seizure disorders, but they are not typically observed in lithium toxicity.

A. Evaluate the parent's understanding of the emergency measures to take in the event of accidental chemical exposure. B. Inform the parent about the risks of exposure to chemical agents. C. Call the poison control center regarding possible chemical exposure. D. Instruct the parent to secure the cleaning supplies in an area that is out of reach of the child.

Correct Answer is C

Explanation

C. Calling the poison control center is the immediate and most important action to take in cases of potential poisoning or chemical exposure. Poison control centers have trained professionals who can provide immediate guidance on how to assess the situation, provide first aid if necessary, and determine if further medical evaluation or treatment is needed.

A. While assessing the parent's understanding of emergency measures is important, it may not be the first action to take in this situation.

B. Providing information about the risks of chemical exposure can be helpful for prevention, but it may not be the first action to take when there is uncertainty about whether the child has ingested a harmful substance.

D. While securing cleaning supplies to prevent future incidents is important, it is not the first action to take when there is concern about a potential ingestion.

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A nurse is speaking with a client who experienced physical assault. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?

Correct Answer is A

Explanation

A home care nurse is speaking with a parent who saw their child playing with cleaning supplies. The parent is not sure if the child ingested anything. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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