Following the visit, what are appropriate actions for the nurse? Select all that apply.

Mail education items to the home for batterer treatment options

Provide referrals from the physician for mental health services

Follow up with the client in a few weeks

Call the police as a mandatory reporter

Document verbatim statements about the abuse

Answer and Explanation

Correct Answer : B,C,E

A.   Mailing education items to the home for batterer treatment options might not be appropriate without the client's consent or discussion.
B.   Providing referrals for mental health services aligns with addressing the client's needs.
C.   Following up with the client in a few weeks ensures continuity of care and monitoring of the client's progress.
D.   Calling the police as a mandatory reporter might be necessary if there's an immediate threat, but it's not mentioned in the scenario.
E.   Documenting verbatim statements about the abuse is crucial for accurate record-keeping and legal purposes.

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Correct Answer is D

Explanation

A. "Client has been sexually assaulted" is a formal and concise description. However, it isn’t written as a client would say it which is a key requirement in documentation of the presenting complaint.
B. "Client reported that she had sexual relations against her will" might be accurate but doesn't convey the severity of the situation as clearly as the term "sexually assaulted."
C. "Client claims that she was forced to participate in sexual intercourse" might describe the situation but doesn't necessarily reflect the urgency or trauma of the incident.
D. "Client states, 'My date raped me tonight'" is documented in the client’s own words and is descriptive enough to be the presenting complaint.

A. Urinary output. B. Blood pressure. C. Respiratory rate. D. Temperature

Correct Answer is B

Explanation

A. Urinary output might be important in some contexts but is not the priority related to the use of MAO inhibitors.
B. MAO inhibitors like phenelzine can affect blood pressure significantly; monitoring BP is crucial due to the risk of hypertensive crisis when certain foods or medications are taken.
C. Respiratory rate might be a consideration in some situations but is not directly affected by MAO inhibitors.
D. Temperature is not typically a primary concern related to MAO inhibitor use; blood pressure monitoring is more crucial due to potential interactions.

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Following the visit, what are appropriate actions for the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

Correct Answer is D

Explanation

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Correct Answer is B

Explanation

An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

A male client tells the nurse that he does not want to take the atypical antipsychotic drug olanzapine because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

The nurse is assessing a client who reports using cocaine several times in the past week.Which observations should the nurse expect on assessment?