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 B

Explanation

The nurse should ask this question to support safe medication administration because the client is to receive medications that are highly teratogenic. Teratogens are substances that can cause congenital disorders and fetal abnormalities.

The nurse should avoid giving teratogenic medications to pregnant clients or clients who may become pregnant.

Choice A is wrong because the family history of cancer is not relevant to the teratogenic effects of the medications.

Choice C is wrong because the previous experience of severe side effects from a drug is not related to the risk of fetal harm.

Choice D is wrong because the allergy to any prescription or non-prescription drugs is not specific to the teratogenic potential of the medications.

A. “I don’t want to know this. Tell your health care provider.”. B. “I’m your nurse and you can tell me anything.”. C. “I’ll close the door first so that no one will hear you.”. D. “I can’t promise that the information won’t be shared if your health or safety is involved.”.

Correct Answer is D

Explanation

“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.

Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.

Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.

Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.

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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

A client is to receive medications that are highly teratogenic. What question should the nurse ask the client to support safe medication administration?

Correct Answer is B

Explanation

A client states “I have something to tell you in confidence.” Which response by the nurse would be appropriate?

Correct Answer is D

Explanation

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

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The nurse is assessing a client experiencing acute pain. What assessments should validate the client with acute pain? Select all that apply.

Which needle gauge should a nurse select when administering a medication subcutaneously?

The nurse is educating a client with insomnia how to promote better sleep. Which interventions should she include for this client? (Select all that apply).