A nurse is assisting in the care of a client. Nurses' Notes 2000:
Client presents to emergency department and states, "I have been assaulted." Client was immediately placed in a treatment room.
2015:
"Client states they were out with friends this evening and had "a little too much to drink." 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." Client reports history of depression. Client is a full-time college student who lives with roommates. 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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Headaches are a common side effect of isosorbide dinitrate, especially when initially starting the medication. However, they often improve as the body adjusts to the medication. It is important to reassure the client that the headaches should decrease over time. If the headaches persist or worsen, the client should inform their healthcare provider for further evaluation and possible adjustment of the medication regimen.
The statement about taking the medication on an empty stomach is not relevant to preventing headaches associated with isosorbide dinitrate.
The statement about swallowing the tablet whole does not address the issue of headaches. Chewable isosorbide dinitrate is designed to be chewed or dissolved in the mouth, and swallowing it whole may not provide the intended therapeutic effect.
Discontinuing the medication until the headache goes away is not recommended without consulting the healthcare provider. Abruptly stopping or changing the dose of isosorbide dinitrate can have serious consequences and should only be done under medical supervision.
Correct Answer is A
Explanation
Explanation
A. Fidelity involves keeping promises made to clients
Fidelity is an ethical principle that pertains to the nurse's duty to be faithful, loyal, and keep promises made to clients. It involves acting in a trustworthy and reliable manner, maintaining commitments, and upholding the client's rights and autonomy.
Option B is incorrect because it refers to autonomy, which is another ethical principle that involves respecting the client's right to make their own health care decisions.
Option C is incorrect because it refers to nonmaleficence, which is the principle of ensuring that we do no harm to the client and avoiding actions that may cause harm or have a negative impact on the client's well-being.
Option D is incorrect because it refers to justice, which involves treating every client with fairness, equality, and respect, but it does not specifically address the concept of fidelity.
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