A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 3 interventions the nurse should plan to take.

Encourage the client to think positive thoughts.

Assist the client in distinguishing between anxiety and physical manifestations.

Provide relief measures for manifestations the client is experiencing.

Inform the client that nothing is medically wrong with them.

Suggest to the client's provider that multiple tests need to be performed.

Perform a lengthy exam of client's condition.

Answer and Explanation

Correct Answer : B,C,E

A. Encourage the client to think positive thoughts. While promoting positive thinking can be helpful, this approach may oversimplify the client's experience and does not address their anxiety or physical symptoms effectively.
B. Assist the client in distinguishing between anxiety and physical manifestations. This intervention is crucial as it helps the client understand the connection between their anxiety and physical symptoms. It can empower the client to better manage their feelings and reduce their fixation on health issues.
C. Provide relief measures for manifestations the client is experiencing. Addressing the client's physical symptoms, such as anxiety and stomach discomfort, is important for their overall well-being and can improve their quality of life.
D. Inform the client that nothing is medically wrong with them. This statement may dismiss the client's concerns and could lead to feelings of frustration or invalidation. It is important to listen to the client’s experiences without minimizing them.
E. Suggest to the client's provider that multiple tests need to be performed. Given the client's report of ongoing symptoms and concerns about their health, it is appropriate to recommend further evaluation to rule out any underlying medical issues. This ensures that the client feels heard and their concerns are taken seriously.
F. Perform a lengthy exam of the client's condition. Conducting a lengthy exam may not be necessary at this stage, especially in an outpatient setting. Instead, focusing on understanding the client's experience and addressing their concerns is more beneficial.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. The client complains of pelvic soreness. Pelvic soreness is a common physical symptom following sexual abuse due to trauma, forced penetration, or muscle tension from psychological distress.
B. The client's urine sample is positive for chlamydia. Sexually transmitted infections (STIs), such as chlamydia, can be a result of sexual abuse. A positive test in a client who has not engaged in consensual sexual activity raises concern for recent or past assault.
C. The client has anal bleeding. Anal trauma, including bleeding, is a strong indicator of possible sexual abuse, especially if there is no medical history of other conditions like hemorrhoids or anal fissures.
D. The client has bruising around the breasts. Unexplained bruising in sensitive areas such as the breasts may suggest physical force during a sexual assault, making this a concerning finding.
E. The client's underwear is bloody. Bloodstains on underwear can indicate genital or anal trauma, which may occur during sexual abuse. This finding warrants further medical and forensic evaluation.
F. The client has a scar on their inner thigh. While scars may suggest past trauma or injury, they do not necessarily indicate recent sexual abuse. Unlike fresh injuries, scars do not provide evidence of a recent assault and are not specific to sexual abuse.

A. Encourage the client to use relaxation techniques. B. Reassure the client that pain is an expected part of their disorder. C. Explain to the client that the pain is not real. D. Assess the client's vital signs.

Correct Answer is D

Explanation

A. Encourage the client to use relaxation techniques. While relaxation techniques can help manage symptoms in somatic symptom disorder, they should not be the first response to a new symptom like chest pain. The nurse must first rule out a medical cause before assuming the pain is psychological.
B. Reassure the client that pain is an expected part of their disorder. Assuming that the pain is purely psychosomatic without assessing for a potential medical emergency could lead to a delay in necessary treatment. Each new symptom should be evaluated independently.
C. Explain to the client that the pain is not real. The pain experienced by clients with somatic symptom disorder is real to them, even if a physical cause is not found. Dismissing their symptoms can damage trust and discourage them from reporting future concerns.
D. Assess the client's vital signs. Any new report of chest pain should be taken seriously, regardless of the client’s psychiatric history. Assessing vital signs ensures that a potential cardiac event or other medical issue is not overlooked before considering psychological factors.

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A nurse is caring for a client in an outpatient clinic. Exhibits Select the 3 interventions the nurse should plan to take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who reports having experienced sexual abuse. The nurse should identify that which of the following findings are consistent with the client's report? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse on an inpatient unit is caring for a client who has somatic symptom disorder. The client comes to the nurse's station and reports chest pain. The nurse knows this is a new symptom for the client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 3 interventions the nurse should plan to take.