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 C

Explanation

C. This statement indicates an understanding of the needs of clients who are part of vulnerable populations because it demonstrates an awareness of the importance of client-centered care. Addressing the problem that the client believes is the most significant acknowledges the client's autonomy, respects their perspective, and ensures that their needs are prioritized.

A. This statement suggests a narrow focus on the immediate reason for the client's visit. While addressing the client's presenting concern is important, a limited assessment may overlook underlying issues or social determinants of health that could impact the client's well-being.

B. While privacy is important, asking clients for income or financial information may be necessary to assess their eligibility for financial assistance programs or to understand socioeconomic factors that may impact their health and access to care.

D. This statement suggests overlooking the importance of cultural competence in nursing practice. Cultural traditions, beliefs, and practices can significantly influence a client's health beliefs, behaviors, and preferences for care.

A. A. change in personality B. Used cannabis as teenager. C. Age of 50 years D. Family member mirrors client behaviors of psychosis

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.

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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

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Correct Answer is C

Explanation

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