A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?

“It wouldn’t have mattered what you had worn.”.

“The current styles are an invitation to disaster.”.

“Never mind about blame.

That will be determined by the court.”.

Answer and Explanation

The Correct Answer is A

“It wouldn’t have mattered what you had worn.” This response by a nurse is appropriate because it validates the client’s feelings and helps to reduce self-blame. It also conveys that rape is not caused by the victim’s clothing or behavior, but by the perpetrator’s violence and lack of respect.

Choice B. “The current styles are an invitation to disaster.” is wrong because it implies that the client is responsible for the rape and that she could have prevented it by dressing differently. This response is judgmental and insensitive, and may increase the client’s guilt and shame.

Choice C. “Never mind about blame.

That will be determined by the court.” is wrong because it dismisses the client’s feelings and does not address her emotional needs.

It also suggests that the nurse does not believe the client or support her. This response may make the client feel isolated and distrustful.

Choice D. “Some people don’t have very good self-control.

We have to help them all we can.” is wrong because it excuses the perpetrator’s behavior and shifts the blame to the victim.

It also implies that rape is a result of sexual desire, rather than an act of violence and domination. This response may make the client feel powerless and helpless.

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Correct Answer is D

Explanation

Insulin injection sites are rotated to prevent lipodystrophy, which is a condition where the fat tissue under the skin becomes lumpy or dented due to repeated injections.

Lipodystrophy can affect the absorption and effectiveness of insulin.

Choice A is wrong because bruising is not a common complication of insulin

injections. Bruising can occur if the needle hits a blood vessel, but this can be avoided by using a new needle each time and applying gentle pressure after the injection.

Choice B is wrong because infection is not a common complication of insulin

injections. Infection can occur if the skin is not cleaned properly before the injection or if the needle is contaminated, but this can be prevented by washing the hands and using alcohol swabs.

Choice C is wrong because bleeding is not a common complication of insulin

injections. Bleeding can occur if the needle hits a blood vessel, but this can be minimized by using a new needle each time and applying gentle pressure after the injection.

A. Maintain trust and avoid behaviors that may increase agitation. B. Order the client to go to their room & alert security. C. Tell the client to sit down or risk isolation and loss of privileges. D. Sedate the client after collecting a lithium level.

Correct Answer is A

Explanation

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Insulin injection sites are rotated to prevent which complication to the tissues?

Correct Answer is D

Explanation

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

Correct Answer is A

Explanation

A nurse inadvertently administers an incorrect medication to a client. Which action should the nurse take first?

Which is the most appropriate action when obtaining a sterile urine specimen from an indwelling urinary catheter?

The nurse is assessing a client presenting with diazepam intoxication. What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

The nurse is preparing to perform a physical assessment. What are the four techniques used?

A young woman arrives to the Emergency Department and reports that she was raped and stabbed. What should the nurse do first?

A nurse has received report on four clients. What client should the nurse see first?

A client makes minimal eye contact with others and remains alone in their room during the day. Which question is an important consideration when planning the client’s care?

A home health nurse is providing education to a client discharged with a tracheostomy. Which statement by the client demonstrates teaching has been effective?