The nurse continues caring for the client.
Complete the following sentence by using the lists of options.
The nurse should
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for correct choice:
- Clarify the antibiotic prescription with the provider: The client has a known penicillin allergy, and ceftriaxone is a cephalosporin, which may cross-react with penicillin. The nurse should clarify this prescription to prevent a potential allergic reaction.
- Penicillin allergy: Due to the client's penicillin allergy, it’s essential to ensure that no antibiotics containing penicillin or related compounds are administered. Ceftriaxone should be verified with the provider to avoid causing an allergic reaction.
Rationale for incorrect choices:
- Perform medication reconciliation: While important, medication reconciliation is not as urgent as clarifying the antibiotic prescription to avoid a potential allergic reaction to ceftriaxone.
- Request a prescription for doxycycline: Doxycycline is not needed in this situation, as the prescribed antibiotics are appropriate for treating common STIs following sexual assault. The client is also allergic to doxycycline.
- Potential HIV exposure: HIV post-exposure prophylaxis (PEP) should be considered, but the priority here is to clarify the antibiotics. PEP can be addressed later with informed consent and appropriate protocols.
- Need for prophylaxis for human papillomavirus (HPV): HPV prophylaxis is not part of standard post-sexual assault care. Focus should be on preventing STIs, pregnancy, and HIV rather than HPV at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "The night shift nurse is terrible.": This is an example of displacement, where the client redirects feelings of anger or frustration from a more significant issue, such as personal conflict or stress, onto an unrelated person like the night shift nurse.
B. "If I do what I am supposed to do, it will go away.": This statement reflects an attempt at problem-solving or avoidance rather than displacement. The client is trying to manage the situation directly by taking action, rather than transferring emotions.
C. "I am so angry with my spouse.": This is a direct acknowledgment of the source of the distress (the spouse) and does not involve displacement. The client is openly expressing anger rather than redirecting it onto someone or something unrelated.
D. "I don't know why I am here in the first place.": This reflects denial, where the client avoids recognizing the true reasons for being in treatment. The client is avoiding confronting their feelings or the situation but isn’t displaying displacement.
Correct Answer is ["D","E"]
Explanation
A. Request that security guards restrain the client: This should be a last resort. Restraints can escalate a situation and should only be used when necessary for safety. The nurse should attempt to de-escalate the situation first before involving security.
B. Speak to the client in a loud voice: Speaking loudly can escalate the situation, especially with someone who is already agitated. A calm, composed tone is more effective in de-escalating anxiety and aggression.
C. Stand directly in front of the client: Standing directly in front of the client can be perceived as confrontational and could increase the client's aggression. It's better to maintain a safe distance and stand at an angle, not directly in front of them.
D. Talk to the client using short, simple sentences: This is an appropriate response. When a client is agitated, they may have difficulty processing complex information. Using short, clear sentences can help them better understand and respond.
E. Identify the client's stressors: Understanding the client’s stressors helps the nurse address the root cause of the agitation and provides an opportunity to offer support or alternative coping strategies.
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