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 B

Explanation

Choice A reason: Asking if the client informed her provider about family disagreement shifts focus from addressing her emotional needs to a procedural question. It does not facilitate therapeutic communication or explore the client’s feelings about her family’s opposition. This response fails to support the client’s autonomy or address the psychological impact of her decision, making it less effective in this context.
Choice B reason: Restating the client’s concern about family disagreement uses reflective listening, a therapeutic technique that validates her feelings and encourages further discussion. This approach fosters trust, helps the client process her emotions, and supports her autonomy in deciding on the mastectomy, aligning with patient-centered care principles for addressing sensitive decisions.
Choice C reason: Stating that the nurse would make the same decision introduces personal bias, which is inappropriate in therapeutic communication. It shifts focus from the client’s needs to the nurse’s perspective, potentially undermining the client’s autonomy. This response does not address the family’s opposition or support the client’s decision-making process, making it ineffective.
Choice D reason: Suggesting the client needs family agreement before signing consent undermines her autonomy as a competent adult. Informed consent requires only the client’s understanding and agreement, not family approval. This response dismisses the client’s decision-making capacity and fails to address her emotional concerns about family opposition, making it inappropriate.

A. Subdural hematoma B. Hyperthyroidism C. Renal calculi D. Diabetes mellitus

Correct Answer is A

Explanation

Choice A reason: A subdural hematoma increases complication risk during electroconvulsive therapy (ECT) due to elevated intracranial pressure. ECT-induced seizures can worsen bleeding or cause herniation, posing significant neurological risks. This condition requires careful evaluation, making it the critical risk factor for complications.
Choice B reason: Hyperthyroidism may increase heart rate or metabolic demand but is not a primary risk for ECT complications. With proper management, it poses minimal risk compared to intracranial issues, so this is not the most concerning condition, making it incorrect.
Choice C reason: Renal calculi do not directly impact ECT safety, as they are unrelated to neurological or cardiovascular risks during seizures. This condition is manageable and not a significant complication risk, so it is incorrect for this scenario.
Choice D reason: Diabetes mellitus requires monitoring during ECT due to fasting or medication effects, but it is not a primary risk for complications. With proper glucose management, risks are minimal, so this is incorrect compared to a subdural hematoma’s impact.

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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 is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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