A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

"The police will want to interview you."

"I will call your spouse."

"We'll have to take photographs of those wounds."

"You are safe now."

Answer and Explanation

The Correct Answer is D

D. This statement prioritizes the client's immediate emotional needs by providing reassurance, validation, and a sense of safety in a traumatic situation. It acknowledges the client's distress and communicates empathy and support, which are essential for building trust and rapport and facilitating the client's emotional healing process.
A. The client may feel overwhelmed by the prospect of speaking to the police at that moment, and it may not be the most therapeutic statement to prioritize.
B. Contacting the client's spouse may provide emotional support and assistance, but it may not be the priority therapeutic statement in this situation.
C. The client may already be feeling vulnerable and exposed, and discussing the need for photographs may exacerbate feelings of distress or discomfort.

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Correct Answer is C

Explanation

C. Digoxin toxicity is a serious condition that can occur when there is too much digoxin in the body. It can lead to life-threatening cardiac dysrhythmias. One of the risk factors for digoxin toxicity is low blood levels of potassium, or hypokalemia.
A. Electrolyte imbalances, including hyponatremia (low sodium levels), can contribute to digoxin toxicity. However, a sodium level of 133 mg/dl alone does not directly indicate digoxin toxicity.
B. Blood glucose levels within the normal range (80-120 mg/dl) would not directly indicate digoxin toxicity.
D. Calcium levels within the normal range (8.5-10.5 mg/dl) do not directly indicate digoxin toxicity.

A. Assess breath sounds B. Monitor serum protein levels C. Assess peripheral pulses D. Monitor daily weights

Correct Answer is D

Explanation

D. Furosemide is a diuretic that works by increasing urine output, which in turn reduces fluid retention and swelling. By tracking the client's weight on a daily basis, the nurse can obtain a clear and consistent measure of how much fluid is being lost as a result of the medication.
A. Monitoring respiratory status but it may not be the most direct method for evaluating the effectiveness of furosemide in reducing peripheral edema.
B. Monitoring serum protein levels may provide information about the client's nutritional status and liver function, but it is not typically used as a direct measure of response to furosemide for peripheral edema.
C. Improvement in peripheral pulses may indicate a reduction in fluid overload and resolution of edema. However, changes in peripheral pulses may be influenced by factors other than diuresis, such as vascular disease or cardiac function.

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A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

Correct Answer is C

Explanation

The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

Correct Answer is D

Explanation

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