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.
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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Related Questions
Correct Answer is C
Explanation
A. Late-onset schizophrenia typically presents with symptoms such as hallucinations, delusions, disorganized thinking, and social withdrawal. However, this does not differentiate it from typical schizophrenia.
B. Substance use, including cannabis use, is a known risk factor for the development of schizophrenia, particularly in individuals who are genetically predisposed to the disorder. However, cannabis use as a teenager alone does not necessarily indicate late-onset schizophrenia.
C. Paraphrenia or late onset schizophrenia generally occurs later in life and symptoms persist and intensify as the client ages. Schizophrenia is rarely diagnosed after the age of 40 and is considered late onset if diagnosed after the age of 40.
D. Family history of psychosis or schizophrenia is a significant risk factor for developing schizophrenia, including late-onset schizophrenia. However, having a family member who mirrors the client's behaviors of psychosis is not a specific finding indicative of late-onset schizophrenia.
Correct Answer is C
Explanation
C. Agranulocytosis is a serious side effect associated with clozapine, an antipsychotic medication. Agranulocytosis is characterized by a severe reduction in the number of white blood cells (specifically granulocytes) in the bloodstream, leading to an increased risk of infection. The client should be educated to monitor for signs and symptoms of agranulocytosis, including sore throat, fever, chills, and muscle aches, as these may indicate an underlying infection due to neutropenia.
A. Severe restlessness may be a side effect of some antipsychotic medications, but it is not specifically associated with agranulocytosis.
B. Respiratory depression and a comatose state are not typical manifestations of agranulocytosis.
D. Increased anxiety and suicidal ideations may be symptoms of certain mental health conditions or adverse effects of psychiatric medications, but they are not characteristic of agranulocytosis.
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