A nurse is preparing to discharge a client who was treated for sexual assault. Prior to discharge, which of the following actions should the nurse plan to take?

Provide the client with grooming supplies and a private area to bathe.

Call the client's home for someone to pick up the client

Retain the client's cell phone for evidence.

Send the client's clothes to the laundry before returning the items to the client.

Answer and Explanation

The Correct Answer is A

A. Provide the client with grooming supplies and a private area to bathe: After evidence collection and medical treatment are complete, allowing the client to bathe in privacy supports their dignity and helps restore a sense of control. This is a therapeutic and appropriate step prior to discharge.
B. Call the client's home for someone to pick up the client: Contacting someone without the client's consent could breach confidentiality and potentially endanger the client, especially if the assailant lives in the same household.
C. Retain the client's cell phone for evidence: The nurse does not have the authority to confiscate personal property like a cell phone. Evidence collection must follow legal protocols, typically involving law enforcement and forensic teams.
D. Send the client's clothes to the laundry before returning the items to the client: The client's clothing may be part of the forensic evidence. Washing or returning them before proper processing would compromise the legal chain of custody.

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Correct Answer is B

Explanation

A. The liver releases glucagon to regulate blood glucose levels: The liver does release glucagon, but glucagon's role is to stimulate the liver to release glucose into the bloodstream, not to regulate blood glucose directly. Glucagon is released in response to low blood glucose levels to raise them, but the adrenal glands play a larger role in regulating glucose in the short term.
B. The adrenal glands release epinephrine and norepinephrine to respond to low blood glucose: When blood glucose levels drop, the adrenal glands release epinephrine (adrenaline) and norepinephrine. These hormones stimulate glucose release from the liver and promote glucose production to help increase blood sugar levels. This is the correct response to hypoglycemia, as these hormones help combat low blood sugar quickly.
C. Glycogenesis occurs in the pancreas when blood glucose levels fall: Glycogenesis refers to the process of glucose being stored as glycogen, primarily in the liver and muscles, and not the pancreas. When blood glucose levels fall, glycogenolysis (the breakdown of glycogen into glucose) occurs, not glycogenesis, to raise glucose levels. The pancreas releases insulin and glucagon, but not for storing glucose.
D. The brain uses protein for energy if glucose levels fall too low: While the brain primarily uses glucose for energy, when glucose levels are critically low, it will use ketones, not protein, for energy. Protein breakdown for energy is typically a later response, and the body generally tries to prevent using protein for energy as long as possible due to its importance in cellular functions.

A. Hypertension B. Lower abdominal pain C. Mental confusion D. Frothy urine E. Weak urine stream F. Fish-type urine odor

Correct Answer is ["A","C"]

Explanation

A. Hypertension: Hypertension is a common manifestation in clients with pyelonephritis, especially in severe or untreated cases. The infection can cause kidney inflammation and disrupt normal kidney function, leading to elevated blood pressure as the kidneys struggle to regulate fluid balance and sodium.
B. Lower abdominal pain: Lower abdominal pain is typically associated with bladder infections (cystitis), not pyelonephritis. Pyelonephritis usually causes flank or costovertebral angle pain due to the involvement of the kidneys, rather than localized lower abdominal discomfort.
C. Mental confusion: Mental confusion can be a sign of systemic infection, particularly in elderly clients or those with severe pyelonephritis. It may indicate that the infection has led to sepsis or that the kidneys are no longer able to filter toxins effectively, affecting mental status.
D. Frothy urine: Frothy urine may be seen in cases of proteinuria, but it is not a classic or primary sign of pyelonephritis. While kidney function impairment can occur in severe infections, frothy urine is more often associated with nephrotic syndrome or glomerular disease.
E. Weak urine stream: A weak urine stream is not a typical manifestation of pyelonephritis. This symptom is more commonly associated with lower urinary tract issues such as benign prostatic hyperplasia or urinary retention.
F. Fish-type urine odor: Fish-type urine odor is not characteristic of pyelonephritis. It is more often associated with infections caused by specific bacteria such as Proteus species, which can lead to a distinct odor, but it is not a typical presentation for pyelonephritis.

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A nurse is preparing to discharge a client who was treated for sexual assault. Prior to discharge, which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","C"]

Explanation

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