The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's

case.

Mark whether the statement by the student nurse indicates understanding or no understanding.

"If the client decides not to report their friend to the police, it is still a good idea to collect the evidence."

"Even if the client will not call the police, the nurse should advise the

"Even if the client will not call the police, the nurse should advise the police of what has happened."

"Consent is not required to collect evidence from a person who has been sexually assaulted."

"The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert."

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

"If the client decides not to report their friend to the police, it is still a good idea to collect the evidence." Understanding: This statement acknowledges the importance of preserving evidence even if the client chooses not to involve the police. Collecting evidence can be crucial for future legal proceedings or for the client's own decision-making process.
-"Even if the client will not call the police, the nurse should advise the police of what has happened." No understanding: This statement suggests that the nurse should bypass the client's autonomy and directly involve the police without the client's consent. It fails to recognize the importance of respecting the client's autonomy and confidentiality.
-"The client has to consent in order for me to document his injuries in the chart." Understanding: This statement demonstrates an understanding of the importance of obtaining the client's consent before documenting any information related to their care, including injuries, in their medical chart.
-"Consent is not required to collect evidence from a person who has been sexually assaulted." No understanding: This statement is incorrect. Consent is always required, even when collecting evidence from a person who has been sexually assaulted. Failing to obtain consent could violate the individual's rights and lead to legal and ethical repercussions.
-"The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert." Understanding: This statement correctly
Prepared by Brandel
identifies that sexual assault exams should ideally be performed by trained professionals, such as Sexual Assault Nurse Examiners or emergency room physicians with expertise in forensic examinations. These professionals are better equipped to handle the sensitive nature of such exams and collect evidence effectively.

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Correct Answer is A

Explanation

A. This comment acknowledges the client's behavior without making assumptions or judgments about the content of the hallucinations. It validates the client's experience and opens the door for further discussion if the client wishes to share more about what they are experiencing.
B. This comment does not directly address the client's current experience and may not be as helpful in validating the client's reality.
C. This comment focuses on redirecting the client's attention rather than acknowledging their experience, which may not be as therapeutic in this context.
D. This comment may invalidate the client's experience by directly contradicting their perception of reality. It is important to avoid dismissing or denying the client's experiences without further assessment and understanding.

A. "The snakes on the wall are going to eat me." B. "The nurse at night is trying to poison me with pills." C. "The voices are telling me to kill the next person I see." D. "The fire is burning my skin away right now." E. None F. None

Correct Answer is B

Explanation

A. "The snakes on the wall are going to eat me." describes a visual hallucination, not a delusion. Hallucinations involve false sensory perceptions, such as seeing things that are not present. While hallucinations are common in schizophrenia, this statement does not indicate a delusion.

B. "The nurse at night is trying to poison me with pills." confirms a delusion, specifically a paranoid delusion. Delusions are fixed, false beliefs that are not based in reality and cannot be changed by logic or reasoning. In this case, the client irrationally believes that the nurse is trying to harm them, which is a classic symptom of schizophrenia.

C. "The voices are telling me to kill the next person I see." describes an auditory hallucination, which involves hearing voices or sounds that are not real. While auditory hallucinations are a common symptom of schizophrenia, this statement does not indicate a delusion.

D. "The fire is burning my skin away right now." describes a tactile hallucination, where the client falsely perceives sensations (e.g., burning). This is another form of hallucination, not a delusion, as it involves sensory misperception rather than a false belief.

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The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Correct Answer is A

Explanation

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

Correct Answer is B

Explanation

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

The nurse is caring for a client Exhibits In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's

case.

Mark whether the statement by the student nurse indicates understanding or no understanding.