A college student experienced a sexual assault when out on a date. After several weeks of crisis intervention therapy, which statement by the client would indicate to the nurse that the student is making progress?

"My boyfriend is too passionate for me."

"I know it was not my fault."

"I'll just go on double dates from now on."

"Next time I won't wear such a sexy dress."

Answer and Explanation

The Correct Answer is B

B. This statement demonstrates progress and indicates that the client is beginning to take responsibility off themselves for the sexual assault. Acknowledging that the assault was not their fault is a crucial step in healing from trauma. It shows an acceptance of reality and a shift away from self-blame or feelings of guilt.
A. It may indicate that the client is still struggling to acknowledge the true nature of the assault and may not have fully processed their feelings and experiences related to the trauma.
C. This statement may suggest avoidance or attempts to control future situations to prevent similar experiences. While seeking support and safety measures can be beneficial, solely relying on external factors such as double dates to prevent sexual assault may not address underlying issues or promote healing from the trauma.
D. It suggests a continuation of internalized victim-blaming beliefs and may indicate that the client has not fully shifted away from feelings of guilt or responsibility for the assault.

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Correct Answer is D

Explanation

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

A. calling staff to place the child in the locked seclusion room. B. placing the child in physical restraints. C. providing a prn anxiolytic medication. D. suggesting that the child go into the gym and shoot some baskets.

Correct Answer is D

Explanation

D. It offers the child a constructive way to release pent-up energy and frustration in a safe and non- confrontational manner. Physical activity can be a helpful tool in managing anger and disruptive behavior, as it allows the child to channel their emotions into a productive activity.
A. This option is not appropriate because it involves isolating the child in a locked room, which could further escalate the situation and may traumatize the child. Seclusion should only be used as a last resort in situations where the child or others are at risk of harm.
B. Physical restraints should only be used as a last resort in situations where the child poses an immediate danger to themselves or others. Using physical restraints can escalate the situation and may cause physical and psychological harm to the child.
C. Medication may be prescribed to manage symptoms of oppositional defiant disorder. However, using a PRN (as needed) anxiolytic medication to manage acute agitation should only be done under the guidance of a healthcare provider.

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A college student experienced a sexual assault when out on a date. After several weeks of crisis intervention therapy, which statement by the client would indicate to the nurse that the student is making progress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Correct Answer is D

Explanation

An 11-year-old, who is diagnosed with oppositional defiant disorder, becomes angry and disruptive over the rules of the day treatment program. The nurse should de-escalate the situation by:

Correct Answer is D

Explanation

A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

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