A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Ineffective community coping.

B Disturbed sensory perception.

Self-care deficit.

Acute confusion.

Answer and Explanation

The Correct Answer is D

A.   Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B.   Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C.   While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D.   Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

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Correct Answer is A

Explanation

A. The CAGE questionnaire focuses on four key aspects related to alcohol use: efforts to Cut down, Annoyance with questions about drinking, feelings of Guilt about drinking, and using alcohol as an "Eye-opener" in the morning. Exploring these aspects in depth can provide valuable information about the client's relationship with alcohol and potential problems.

B. While information about consumption, liver enzymes, and gastrointestinal complaints is important for assessing alcohol-related issues, these are not specifically addressed by the CAGE questionnaire.
C. Cancer screening results, anger, gastritis, and daily alcohol intake are relevant to assessing the client's overall health and alcohol use but are not directly related to the questions asked in the
CAGE questionnaire.
D. While information about minimizing drinking, missing family events, guilt about drinking, and daily alcohol intake may provide insight into the client's alcohol use, these aspects are not specifically addressed by the questions in the CAGE questionnaire.

A. "If the client decides not to report their friend to the police, it is still a good idea to collect the evidence." B. "Even if the client will not call the police, the nurse should advise the C. "Even if the client will not call the police, the nurse should advise the police of what has happened." D. "Consent is not required to collect evidence from a person who has been sexually assaulted." E. "The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert."

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

"If the client decides not to report their friend to the police, it is still a good idea to collect the evidence." Understanding: This statement acknowledges the importance of preserving evidence even if the client chooses not to involve the police. Collecting evidence can be crucial for future legal proceedings or for the client's own decision-making process.
-"Even if the client will not call the police, the nurse should advise the police of what has happened." No understanding: This statement suggests that the nurse should bypass the client's autonomy and directly involve the police without the client's consent. It fails to recognize the importance of respecting the client's autonomy and confidentiality.
-"The client has to consent in order for me to document his injuries in the chart." Understanding: This statement demonstrates an understanding of the importance of obtaining the client's consent before documenting any information related to their care, including injuries, in their medical chart.
-"Consent is not required to collect evidence from a person who has been sexually assaulted." No understanding: This statement is incorrect. Consent is always required, even when collecting evidence from a person who has been sexually assaulted. Failing to obtain consent could violate the individual's rights and lead to legal and ethical repercussions.
-"The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert." Understanding: This statement correctly
Prepared by Brandel
identifies that sexual assault exams should ideally be performed by trained professionals, such as Sexual Assault Nurse Examiners or emergency room physicians with expertise in forensic examinations. These professionals are better equipped to handle the sensitive nature of such exams and collect evidence effectively.

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A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

Correct Answer is A

Explanation

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

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