A nurse is assisting in the care of a client. Nurses' Notes

2000:

The client presents to the emergency department and states, "I have been assaulted." The client was immediately placed in a treatment

room. 2015:

"The client states they were out with friends this evening and had "a little too much to drink." The client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." The client reports a history of depression. The client is a full-time college student who lives with roommates. The client admits to drinking socially but denies illicit drug use and tobacco use.

Which of the following interventions should the nurse plan to implement? Select all that apply.

Contact children and youth services.

Provide resources to the client for the local Alcoholics Anonymous chapter.

Request a consult for case management.

Maintain a safe and private environment for the client.

Administer sexually transmitted infection prophylaxis.

Provide resources for local support services.

Answer and Explanation

Correct Answer : C,D,E,F

Case management can be beneficial in situations involving assault to help coordinate and provide ongoing support and resources for the client. This intervention is appropriate in this scenario.

Ensuring a safe and private environment is crucial to protect the client's confidentiality and provide a supportive atmosphere during this difficult time. This intervention is necessary.

Since the client reports being assaulted and has sore genitals, it is important to consider the risk of sexually transmitted infections (STIs). Administering STI prophylaxis can help prevent potential infections.

The client may benefit from additional support services such as counseling or support groups. Providing resources for local support services can help the client access the necessary help and support they need.

Contacting children and youth services is not applicable in this scenario as the client is a full-time college student and not a child or youth.

While the client mentioned drinking, it is not explicitly stated that they have an alcohol addiction or problem. Therefore, providing resources for Alcoholics Anonymous may not be the most appropriate intervention at this time.

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Correct Answer is B

Explanation

During an intravenous pyelogram (IVP), a contrast dye is injected into the client's veins, and X-ray images are taken to visualize the urinary tract. The dye used in an IVP can cause a warming or flushing sensation as it circulates through the body. The client's statement indicates an understanding of this common sensation associated with the procedure.
A. "I can have a meal up to 2 hours before the procedure": This statement is incorrect. Typically, for an IVP, the client is required to have an empty stomach before the procedure to ensure accurate imaging results. The client should follow the specific instructions provided by their healthcare provider regarding fasting before the procedure.
C. "I do not need to sign a consent form before this procedure": This statement is incorrect. Informed consent is required for most medical procedures, including an IVP. The client should sign a consent form after receiving all the necessary information about the procedure, its risks, and benefits.
D. "I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. After an IVP, it is generally advised to increase fluid intake to help flush out the contrast dye from the body and prevent potential complications. The client should follow the specific instructions provided by their healthcare provider regarding post-procedure fluid intake.

A. Apply the restraint under the client's clothes. B. Tie the restraint to the railing of the client's bed. C. Place the client in a sitting position. D. Ensure the restraint is placed across the client's chest.

Correct Answer is C

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

Correct Answer is C

A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include? (Select all that apply)

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicates the need for further evaluation? Select all that apply.

A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?