A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

Instruct the client to shower and change their clothes.

Ask the client for details about the assault.

Reassure the client that their injuries are not life-threatening.

Limit the number of staff members providing care for the client.

Answer and Explanation

The Correct Answer is D

Choice A reason: Instructing the client to shower and change clothes is inappropriate, as it may destroy forensic evidence critical for legal proceedings. Evidence preservation is a priority post-sexual assault, and showers are delayed until after forensic examination, making this intervention incorrect and potentially harmful.
Choice B reason: Asking for details about the assault can retraumatize the client and is not the nurse’s role immediately post-assault. Trained forensic examiners or counselors handle such discussions sensitively. This action risks emotional harm and is inappropriate for initial care, making it incorrect.
Choice C reason: Reassuring the client that injuries are not life-threatening may minimize their trauma and emotional distress. The focus should be on emotional support and safety, not downplaying injuries, which may be perceived insensitively. This intervention is inappropriate for trauma-informed care, making it incorrect.
Choice D reason: Limiting staff members providing care reduces the client’s exposure to multiple providers, minimizing retraumatization and ensuring consistency. This trauma-informed approach fosters trust and safety post-sexual assault, aligning with best practices for psychological support, making it the correct intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Frequent swallowing is a key indicator of post-tonsillectomy hemorrhage, as the child may swallow blood from bleeding in the surgical site. This subtle sign requires urgent assessment to prevent airway obstruction or significant blood loss, aligning with clinical priorities, making it the correct finding.
Choice B reason: Increased drowsiness may indicate pain medication effects or general recovery but is not specific to hemorrhage. While concerning, it is less urgent than frequent swallowing, which directly suggests bleeding, making this finding less indicative of hemorrhage in this context.
Choice C reason: Elevated pain is expected post-tonsillectomy due to surgical trauma and does not specifically indicate hemorrhage. Pain may persist regardless of bleeding, so this finding is less reliable than frequent swallowing for identifying potential hemorrhage, making it incorrect.
Choice D reason: Diminished breath sounds suggest respiratory complications like atelectasis or obstruction, not hemorrhage. Bleeding would more likely present with swallowing or visible blood. This finding is unrelated to tonsillectomy hemorrhage, making it an incorrect indicator for this complication.

A. Bilirubin B. Alkaline phosphatase C. Amylase D. Creatinine

Correct Answer is D

Explanation

Choice A reason: Bilirubin assesses liver function, not kidneys. Cyclosporine’s nephrotoxicity affects glomerular filtration, not heme metabolism. Monitoring bilirubin is irrelevant for renal function in transplant clients, as it reflects hepatic or hemolytic processes, not kidney health or drug toxicity.
Choice B reason: Alkaline phosphatase evaluates liver or bone health, not kidneys. Cyclosporine may cause hepatotoxicity, but renal monitoring is critical due to its nephrotoxic potential. Alkaline phosphatase does not reflect glomerular or tubular function, making it unsuitable for assessing renal impact.
Choice C reason: Amylase measures pancreatic function, not kidneys. Cyclosporine’s nephrotoxicity affects renal filtration, not pancreatic enzymes. Monitoring amylase is irrelevant for kidney transplant clients, as it does not indicate renal impairment or cyclosporine’s toxic effects on kidney function.
Choice D reason: Creatinine is a key renal function marker, reflecting glomerular filtration rate. Cyclosporine’s nephrotoxicity elevates creatinine, indicating kidney damage. Monitoring it with BUN ensures early detection of renal impairment, guiding dose adjustments to prevent further injury in transplant clients.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is A

Explanation

A nurse is reviewing the BUN result of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory studies should the nurse recognize as another renal function study that should be monitored?

Correct Answer is D

Explanation

A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

A nurse is reviewing home care with a client who has multiple sclerosis. Which of the following precautions should the nurse recommend to promote client safety?

A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto?

A nurse is preparing a sterile field for a client who requires a sterile procedure. Which of the following actions should the nurse plan to take?

A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the preceptor?

A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?