The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

"We need to offer the client emotional support especially when obtaining specimens."

"Did you see that outfit that the client is wearing? What did they expect?"

The client feels like they won't be believed since there was alcohol involved during the date."

"When the client said "stop." that was enough for the perpetrator to get up and walk away."

Answer and Explanation

The Correct Answer is B

Explanation: This statement is highly inappropriate and victim-blaming. It implies that the client's clothing choices are somehow responsible for the sexual assault they experienced. Victim-blaming is never acceptable and can be harmful to the survivor, making them feel ashamed and responsible for the actions of the perpetrator. As healthcare professionals, nurses should always respond to victims of sexual assault with empathy, compassion, and without judgment.

The other statements (A, C, and D) are all appropriate and acknowledge the seriousness of the situation:

A. "We need to offer the client emotional support especially when obtaining specimens." Explanation: This statement recognizes the need for emotional support during the examination process, which can be distressing for the survivor. Providing emotional support and ensuring the client's comfort and consent during the examination are crucial aspects of caring for a sexual assault survivor.

C. "The client feels like they won't be believed since there was alcohol involved during the date." Explanation: This statement highlights the survivor's feelings and concerns about being believed due to alcohol involvement. It emphasizes the importance of creating a safe and non-judgmental environment for the client, where they can share their experience and receive appropriate care and support.

D. "When the client said 'stop,' that was enough for the perpetrator to get up and walk away." Explanation: This statement indicates an understanding of the importance of consent and acknowledges that the client's clear expression of refusal should have been respected. Understanding and respecting consent is crucial when discussing cases of sexual assault.

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Correct Answer is A

Explanation

Explanation: Crackles are abnormal lung sounds that may indicate the presence of fluid or mucus in the lungs. Placing the client on bed rest in a semi-Fowler position helps to improve lung expansion and oxygenation by reducing the pressure on the diaphragm, promoting optimal lung ventilation, and facilitating drainage of fluid from the affected area of the lung.

The other interventions are not appropriate for crackles in the left lower lobe:

B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.

C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.

D- Repeating auscultation after asking the client to breathe deeply and cough may help the nurse gather more information about the client's lung sounds, but it does not address the immediate need for improving lung expansion and oxygenation in the presence of crackles.

A. "You may be in more physical danger after you leave them." B. "Batterers never change, so it would be best for you to leave." C. "If you leave, maybe your partner will see that they have to change their behavior." D. "If you don't leave. your partner will think you're going to continue to endure the abuse."

Correct Answer is C

Explanation

This response is the most supportive and empowering for the client. It acknowledges the client's agency in making decisions about their own life and relationship. It also conveys hope that leaving the abusive relationship may prompt the partner to realize the need to change their behavior. It does not impose judgment or make assumptions about the outcome, but instead, it recognizes the client's strength and potential for positive change.

Option A may instill fear and discourage the client from taking action to protect themselves.

option B generalizes that all batterers never change, which may not be true for all situations and individuals.

Option D may imply a threat or ultimatum, which is not appropriate and can be disempowering for the client. The most important aspect of supporting someone in an abusive relationship is to provide a non-judgmental, understanding, and empowering environment where they can explore their options and make decisions that are best for their safety and well-being.

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The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

Correct Answer is A

Explanation

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse. "What do you think about that?" Which is the best response by the nurse?

Correct Answer is C

Explanation

A client who has been physically aggressive arrives at the emergency department for a psychiatric assessment. Which approach would be best for the nurse to use?

The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation?

The nurse is meeting with a client who is experiencing complicated grieving from the death of their child to suicide. In order to establish a therapeutic nurse-client relationship, what will the nurse do prior to the meeting?

A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on the appropriate use of seclusion?

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?