A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

Instruct the client to shower and change their clothes.

Ask the client for details about the assault.

Reassure the client that their injuries are not life-threatening.

Limit the number of staff members providing care for the client.

Answer and Explanation

The Correct Answer is D

Choice A reason: Instructing the client to shower and change clothes is inappropriate, as it may destroy forensic evidence critical for legal proceedings. Evidence preservation is a priority post-sexual assault, and showers are delayed until after forensic examination, making this intervention incorrect and potentially harmful.
Choice B reason: Asking for details about the assault can retraumatize the client and is not the nurse’s role immediately post-assault. Trained forensic examiners or counselors handle such discussions sensitively. This action risks emotional harm and is inappropriate for initial care, making it incorrect.
Choice C reason: Reassuring the client that injuries are not life-threatening may minimize their trauma and emotional distress. The focus should be on emotional support and safety, not downplaying injuries, which may be perceived insensitively. This intervention is inappropriate for trauma-informed care, making it incorrect.
Choice D reason: Limiting staff members providing care reduces the client’s exposure to multiple providers, minimizing retraumatization and ensuring consistency. This trauma-informed approach fosters trust and safety post-sexual assault, aligning with best practices for psychological support, making it the correct intervention.

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Correct Answer is D

Explanation

Choice A reason: Adding salt to season foods can irritate oral sores in AIDS patients, often caused by candidiasis or herpes. Salt exacerbates pain and delays healing, making this instruction harmful and inappropriate for managing oral discomfort in this population.
Choice B reason: Rinsing with alcohol-based mouthwash worsens oral soreness, as alcohol irritates mucosal lesions common in AIDS. Non-alcohol, antiseptic, or saline rinses are preferred to promote comfort and healing, making this instruction incorrect and potentially painful.
Choice C reason: Eating hot foods can aggravate oral sores, increasing pain and delaying healing in AIDS patients with mucosal damage. Lukewarm or cool foods are better tolerated, making this instruction inappropriate and counterproductive for managing the client’s symptoms.
Choice D reason: Using ice chips numbs the mouth, reducing pain from oral sores during eating for AIDS patients. This non-invasive, soothing intervention is safe and effective, aligning with comfort-focused care for mucosal lesions, making it the correct instruction.

A. Use a mechanical lift to transfer the client. B. Ask another nurse to assist with the transfer. C. Position the client upright before transferring. D. Use a sliding board to transfer the client.

Correct Answer is A

Explanation

Choice A reason: Using a mechanical lift for a 136 kg client unable to assist ensures safety for both client and nurse. Lifts prevent injury by supporting the client’s weight, reducing strain on staff. This adheres to safe patient handling guidelines, minimizing risks of falls or musculoskeletal injuries during transfer.
Choice B reason: Asking another nurse to assist is insufficient for a 136 kg client unable to help, as manual lifting risks injury to staff and client. Mechanical lifts are required for heavy or non-assistive clients to ensure safety, making this option inadequate and unsafe for the transfer scenario described.
Choice C reason: Positioning the client upright before transfer is impractical for a non-assistive client weighing 136 kg, as it requires significant manual effort and risks injury. Mechanical lifts are needed to safely move such clients, ensuring stability and preventing falls, making this action inappropriate for the transfer.
Choice D reason: A sliding board is unsuitable for a 136 kg client unable to assist, as it requires some patient cooperation and strength. It risks injury to staff and client due to the client’s weight and inability to participate. Mechanical lifts are the safer, recommended method for this transfer.

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A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has AIDS. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?

Correct Answer is D

Explanation

A nurse is planning to transfer a client who weighs 136 kg (300 lb) from a bed to a chair. The client is unable to assist in the transfer. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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