The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

A summary of the client’s feelings

The client’s significant other’s statement

A general description

Photographs

Answer and Explanation

The Correct Answer is D

A.   Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B.   The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D.   Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.

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Correct Answer is C

Explanation

A. Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B. Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D. Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

A. A nurse who works in a pediatric emergency department. B. An adolescent male whose parents recently divorced. C. A retired older male whose significant other has passed away. D. A single working mother with three preschool-aged children.

Correct Answer is B

Explanation

A. While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B. Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D. While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

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The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Correct Answer is C

Explanation

Which individual should the nurse consider at the highest risk for suicide?

Correct Answer is B

Explanation

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?