A nurse is caring for a client in the emergency department (ED). (Item 1/6)

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify the client's
dropdown
and
dropdown
are consistent with sexual assault.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Rationale for correct choices:

Fingernail assessment: Broken fingernails can be a sign of a struggle, as the client may have tried to defend themselves during the assault. Such injuries are commonly seen in cases of sexual assault, where victims may attempt to resist or protect themselves.
Diagnostic results: The positive urine drug screen for GHB is key as it is often used as a "date rape drug" due to its ability to cause sedation, memory loss, and impaired judgment. Its presence supports the possibility of the client being drugged as part of a sexual assault.

Rationale for incorrect choices:

Blood pressure: Blood pressure readings are typically not indicative of sexual assault. While anxiety or trauma can affect blood pressure, this measurement alone does not provide information directly related to sexual assault. Her BP is also within normal range.
Abdominal examination: Mild tenderness in the abdomen could be incidental or related to other causes but is not directly linked to the typical findings in a sexual assault case. Abdominal examination would generally not be the primary assessment for identifying sexual assault unless there was significant trauma or injury to the abdomen.
Temperature: A normal temperature of 37°C (98.6°F) does not indicate anything specific to sexual assault. While fever may occur in cases of infection, it is not a defining characteristic of sexual assault and doesn't help in confirming the occurrence.

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Correct Answer is C

Explanation

A. Occupational therapy: Occupational therapy focuses on helping clients improve their ability to perform daily activities. While beneficial for individuals with Alzheimer's, it does not specifically address the partner’s need for temporary relief from caregiving duties.
B. Palliative care: Palliative care focuses on providing relief from symptoms and improving the quality of life for clients with serious illnesses. While appropriate for end-of-life care, it may not address the partner’s immediate need for respite from caregiving.
C. Respite care: Respite care provides temporary relief for caregivers by allowing them to take a break while ensuring their loved one continues to receive appropriate care. This is the most appropriate referral for the partner, who is seeking time for themselves.
D. Hospice care: Hospice care is focused on end-of-life care, offering comfort and support for clients with terminal illnesses. It is not the best option in this case, as the client is not necessarily at the end of life but has Alzheimer's disease, which is a progressive condition.

A. Transfer a client who has delirium from a bed to a wheelchair. B. Inform a client who has schizophrenia about available community services. C. Obtain a list of current medications from a client who is experiencing a manic episode. D. Insert an NG tube for a client who has acetaminophen toxicity.

Correct Answer is A

Explanation

A. Transfer a client who has delirium from a bed to a wheelchair: Assisting with transfers and mobility is within the scope of practice for an AP, especially if the client is stable and the task does not require clinical decision-making.

B. Inform a client who has schizophrenia about available community services: This task requires clinical judgment and communication skills to ensure that the client understands the information and that the services are appropriate for their needs. It should be performed by a nurse, not an AP.

C. Obtain a list of current medications from a client who is experiencing a manic episode: While obtaining a medication list is an important task, it requires assessment and evaluation of the client's condition, which should be done by a nurse, especially when the client is in a manic state and may have impaired judgment or communication.

D. Insert an NG tube for a client who has acetaminophen toxicity: Inserting an NG tube is an invasive procedure that requires clinical knowledge and skill. It should be performed by a licensed nurse or physician, not an AP.

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A nurse is caring for a client in the emergency department (ED). (Item 1/6) Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should identify the client's dropdownanddropdown are consistent with sexual assault.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a home visit on a client who has Alzheimer's disease and their partner. The partner states, "I wish I had some time to myself and run errands, but I need to be here all the time." Which of the following referrals should the nurse recommend to the client's partner?

Correct Answer is C

Explanation

A charge nurse in an emergency department is assigning tasks. Which off the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is A

Explanation

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A nurse is caring for a client on an acute care mental health unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should immediately follow up on the client's dropdownanddropdown.

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A nurse is caring for a client in the emergency department (ED). (Item 1/6)

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify the client's
dropdown
and
dropdown
are consistent with sexual assault.