The nurse continues to care for the patient

The client is a 19-year-old male who is in the emergency room for a leg injury. He states he was returning to his dorm from a party and fell about 5 feet (1.5 meters) into a small ravine on campus. The client states that he drinks socially and takes no medications for any health condition.

The nurse is listening to the client.

Because the client is a male, he is especially at risk for which psychosocial two sequalae of sexual assault?

Suicide

Depression

Post-traumatic stress disorder

Becoming an abuser

Human immunodeficiency virus

Chlamydia

Answer and Explanation

Correct Answer : B,C

A.   Suicide is a potential risk following sexual assault due to the emotional trauma that can ensue; however, it is not specific to males and therefore not the best answer in this context.
B.   Depression is a common sequela of sexual assault among survivors due to the significant psychological impact of the trauma, which can lead to feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed.
C.   Post-traumatic stress disorder (PTSD) is another frequent outcome of sexual assault, characterized by persistent mental and emotional stress as a result of injury or severe psychological shock. PTSD can manifest in nightmares, flashbacks, and severe anxiety, as well as uncontrollable thoughts about the event.
D.   Becoming an abuser is a potential outcome for some survivors of sexual assault, but it is not one of the most common sequelae and is not supported by the literature as a primary risk for male survivors.
E.   Human immunodeficiency virus (HIV) is a risk in cases of sexual assault where the transmission of bodily fluids occurs, but it is not a psychological sequela and thus not relevant to the question.
F.   Chlamydia, like HIV, is a sexually transmitted infection that can be a risk in cases of sexual assault involving transmission of bodily fluids. However, it is not a psychological sequela and is not specific to the male gender in the context of sexual assault risk factors.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Waiting until the client is completely calm is important because it allows the client to feel safe and secure, reducing anxiety and making it easier for them to open up about sensitive issues.
B. Asking difficult questions first is not typically advised as it can increase anxiety and make the client less likely to disclose information. It's important to build rapport and trust before tackling more challenging topics.
C. Using silence as a tool can give the client time to think and process their thoughts, which can lead to more meaningful communication. It also shows the nurse is patient and willing to listen.
D. Speaking with the client in private ensures confidentiality and helps establish a safe space where the client feels comfortable sharing personal information without fear of judgment or exposure.
E. Observing nonverbal behavior and reacting accordingly is crucial as it can provide insights into the client's emotional state and help the nurse respond in a way that is empathetic and supportive.
F. Asking several questions in a row can overwhelm the client and make it difficult for them to provide thoughtful answers. It's better to ask one question at a time and allow the client to fully respond before moving on to the next question.

A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation. B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation. C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed. D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Correct Answer is A

Explanation

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["A","C","D","E"]

Explanation

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?

Correct Answer is A

Explanation

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

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?

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?