211 Test 3

A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response.

"Are you thinking of harming yourself?"

A client approaches the nurse and loudly states, "I'm not putting up with this anymore!" The most appropriate response by the nurse would be what?

"I can see you are angry. Tell me what's going on."

Which statement indicates that a client requires additional teaching following cataract surgery?

"I can't wait to get back to the gym and lift weights."

The client has been placed in restraints for violent behavior. Which statement best indicates the nurse's understanding of the risk for client injury while being restrained?

"I need someone to continuously monitor the client and relieve me for a few minutes."

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:

"I'd like to talk with you about how you're feeling right now."

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery?

"I'm sleeping better although I still have an occasional nightmare."

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?

"My fingers are tingly."

A client lost control of their behavior, broke a window, and verbally threatened staff and other clients. The nursing team placed the client in mechanical restraints. Which statement by the nurse would be most appropriate to explain the use of restraints to the client?

"This is a means of keeping you and others safe."

The nurse is teaching the client to instill eye drops. Which statement is correct?

"Wash your hands before and after instilling eye drops and do not touch the tip of the bottle."

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care?

A wish for revenge

Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?

A women's shelter

Which assessment finding can help the nurse differentiate a child experiencing child neglect rather than child abuse?

A young child is admitted to the hospital with hypothermia because the child is inadequately dressed.

The 28-year-old is being seen in the ED with injuries after being assaulted by her live-in-boyfriend. The client acknowledges that this is not the first time that she has been assaulted and that she is afraid. Which client action indicates that an outcome for the client has been achieved?

Accepts arrangements made with a women's shelter

The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately?

Acute angle-closure glaucoma

A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.)

Allow the patient to talk at a comfortable pace. Place the patient in a private room with a caregiver. Pose questions in nonjudgmental, empathetic ways.

A nurse is teaching a community group about preventing hearing loss. What instruction is best?

Always wear a bicycle helmet.

Seclusion and restraint are nursing interventions to be used for an individual in which situation?

As a last resort

The older, disheveled client is admitted to the ED with hypertension, severe dehydration, and malnourishment. During the admission interview, the daughter notes that she and her husband, who is temporarily out of work, have been living with the client. Which nursing action is most important?

Ask additional questions of the client in private without the family present.

The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse's primary goal of this seclusion?

Assure the safety of the client and others

A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home?

Avoid bending the head below the waist.

Which sign of escalating behaviors, if displayed by a client, requires immediate intervention?

Banging the head against the wall

A patient had cataract surgery. What instructions would the nurse provide? (Select all that apply.)

Call the doctor for increased pain. Do not bend over from the waist. Do not lift more than 10 lbs. Use stool softeners to avoid constipation.

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child?

Chronic low self-esteem related to negative feedback from parents

The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate?

Conductive

While working in a psychiatric-mental health facility, the nurse notices a client pacing back and forth and becoming increasingly agitated. Which is a critical step in communicating with the client to prevent the escalation of aggressive behavior?

Discover the source of the distress.

A nurse teaches a patient with diabetes mellitus about foot care. Which statements would the nurse include in this patient's teaching? (Select all that apply.)

Do not walk around barefoot."

A 33-year-old client has been treated for a periorbital hematoma and a broken nose that the client suffered when the client's spouse struck the client. The client does not know where the spouse currently is, and the client is scheduled for discharge. What action should the care team prioritize in this client's care?

Ensuring that the client goes to a safe place

A child has been diagnosed with medical abuse by his mother. When setting goals, which is of the highest priority?

Establishing safety of the child

A nurse assesses a patient who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first?

Examine the patient's feet for signs of injury.

A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?

Explain the location of items using clock cues.

A patient is taking timolol (Timoptic) eyedrops. The nurse assesses the patient's pulse at 48 beats/min. What action by the nurse is the priority?

Hold the eyedrops and notify the provider.

The nurse is assessing an 86-year-old client who is hearing impaired. Which intervention should the nurse implement?

Lower your voice pitch while facing the client

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority?

Notify the health care provider to obtain a seclusion order.

A patient is in the preoperative holding area waiting for cataract surgery. The patient says "Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix." What action by the nurse is most important?

Notify the surgeon immediately.

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?

Olanzapine

How should the nurse position a client who has just undergone a stapedectomy?

On the unaffected side

Which clinical scenario predicts the highest risk for directing violent behavior toward others?

Paranoid delusions of being followed by the government

A nurse is seeing patients in the ophthalmology clinic. Which patient would the nurse see first?

Patient who has had cataract surgery and has worsening vision and pain

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger?

Periodically provide an update and progress report on the patient.

An older adult patient that has type 2 diabetes comes to the emergency department with second-degree burns to the bottom of both feet and states, "I didn't feel too hot but my feet must have been too close to the heater." What does the nurse understand is most likely the reason for the decrease in temperature sensation?

Peripheral neuropathy

An elderly client with dementia lives with their daughter but attends a day center during the day. The nurse notices the client is unkempt and smells of urine. Upon examining the client, the nurse notes bruising on the arms and back. From these observations, which type of abuse does the nurse suspect?

Physical abuse

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment?

Physical injuries

The student nurse is performing a Weber tuning fork test. What technique is most appropriate?

Placing the vibrating fork in the middle of the patient's head

A patient's intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best?

Plan to teach about drugs for glaucoma.

After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions?

Risk for injury related to physical abuse from partner

An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority?

Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?

Risk for other-directed violence

A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.)

Select the person who will communicate with the patient. Appoint a person to clear a path and open, close, or lock doors. Remove jewelry, glasses, and harmful items.

The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response.

Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse's initial action?

Stay with the client to protect the client from self-harm until relieved.

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic?

Support the victim to separate issues of vulnerability from blame.

A patient is admitted to the nursing unit after having a tympanoplasty. What activities does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Take and record postoperative vital signs. Remind the patient to lie on the operative side.

The nurse is working with a 17-year-old client with a complex and dysfunctional family background. What aspect of this client's history should the nurse identify as the most significant risk factor for posttraumatic stress disorder (PTSD)?

The client was sexually abused by the mother's boyfriend at a young age

When debriefing the unit's staff after the client's catastrophic reaction, the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse's comment?

The client's safety is at jeopardy if the staff is feeling threatened.

Which behavior by a parent would lead the postpartum nurse to become concerned about the potential for abusive parenting?

The mother does not choose to hold or feed her infant.

The nurse manager, concerned about the potential for staff harm on a behavioral health unit, is assessing the unit's milieu. Which milieu situation should the nurse manager address because it is a predictive factor for violence?

The nurse from a medical unit is assigned to work on the unit.

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient.

The patient agrees to a follow-up appointment with a rape victim advocate.

A college student comes to the counseling center and tells the nurse that they fear their partner. The student states, "My partner is so jealous and overprotective. My partner wants to know where I am and who I'm with every minute and has pushed me a couple of times." Which statement is most likely true regarding this situation?

This is characteristic of the tension-building phase of the violence cycle.

During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?A patient had a myringotomy. The nurse provides which discharge teaching?

Tinnitus and sensorineural hearing loss

A patient has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this patient? (Select all that apply.)

Wash the device with soap and a small amount of warm water. Use a toothpick to clean debris from the device. Be careful not to drop the hearing aid when handling. Turn the hearing aid off when the patient goes to bed.

A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse?

Write down the steps of the procedure for the patient to read before beginning the treatment.

Which client should be assessed as demonstrating aggression?

a client who stomps away from the nurses' station, goes into the day room, and grabs a pool cue from another client standing at the pool table

Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has

bruises on extremities.

A community health nurse visits a home and finds a child who stayed home from school to care for a younger sibling. The nurse observes that the house is cluttered and dirty. When asked about the parents, the child states he does not think his father likes him because he calls him "stupid." The nurse suspects which type of abuse?

emotional abuse

An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on

maintaining physiological stability.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should

make sure there is adequate physical space between the nurse and patient.

A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should (Select all that apply.)

offer the victim a shower after evidence is collected. explain that bathing destroys evidence.

A young client enters the emergency department after being raped by a stranger. What is the first thing that the nurse should do?

provide a safe, private environment