A nurse is speaking with a client who experienced physical assault. Which of the following actions should the nurse take?

Allow the client to control the conversation.

Ask the client a series of questions about who assaulted them.

Insist the client report the incident.

Touch the client for reassurance.

Answer and Explanation

The Correct Answer is A

A. Allowing the client to control the conversation empowers them to share their experience at their own pace and in their own way. This approach fosters trust and facilitates open communication between the nurse and the client.

B. While gathering relevant information about the assault may be necessary for documentation and reporting purposes, it's important to approach the topic with sensitivity and respect for the client's emotional well-being.

C. Pressuring the client to report the incident against their will can further traumatize them and undermine their sense of control. Reporting the assault is a personal decision that should be made by the client based on their individual circumstances and preferences.

D. Touch can be a powerful form of nonverbal communication that conveys empathy, support, and reassurance. However, it's important to obtain the client's consent before initiating any form of physical contact, especially considering the sensitive nature of the situation.

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Correct Answer is B

Explanation

B. Fluctuating cognition and visual hallucinations are characteristic features of Lewy body dementia (LBD). LBD is a type of dementia that involves abnormal protein deposits called Lewy bodies in the brain. These deposits can cause fluctuations in cognitive abilities, leading to periods of clarity alternating with confusion or disorientation. Visual hallucinations are also common in LBD, often involving seeing people, animals, or objects that are not present.

A. Prion diseases are not commonly associated with fluctuating cognitive function.

C. HIV infection can cause a range of neurological complications, but they usually manifest differently from the symptoms described in the scenario.

D. Symptoms of TBI-related dementia would depend on the severity and location of the brain injury, but they often involve cognitive deficits consistent with the area of brain damage

A. Severe restlessness B. Respiratory depression and a comatose state C. Sore throat and muscle aches D. Increased anxiety and suicidal ideations

Correct Answer is C

Explanation

C. Agranulocytosis is a serious side effect associated with clozapine, an antipsychotic medication. Agranulocytosis is characterized by a severe reduction in the number of white blood cells (specifically granulocytes) in the bloodstream, leading to an increased risk of infection. The client should be educated to monitor for signs and symptoms of agranulocytosis, including sore throat, fever, chills, and muscle aches, as these may indicate an underlying infection due to neutropenia.

A. Severe restlessness may be a side effect of some antipsychotic medications, but it is not specifically associated with agranulocytosis.

B. Respiratory depression and a comatose state are not typical manifestations of agranulocytosis.

D. Increased anxiety and suicidal ideations may be symptoms of certain mental health conditions or adverse effects of psychiatric medications, but they are not characteristic of agranulocytosis.

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A nurse is speaking with a client who experienced physical assault. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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