A woman comes to the crisis prevention center anxious and upset. She tells the volunteer nurse who is working as a client advocate that she has been raped. The client says, "I think it is my fault this happened
I should never have worn that tight skirt." Which response by the nurse would be most appropriate? A. "You should not dwell on why it happened. Now you need to deal with the complications that may occur because of the rape."
B. "Your reaction represents a myth. Women do not have to provoke the assailant to be raped."
C. "You need to stop blaming yourself."
D. "Even if you did provoke the assailant by wearing a tight skirt, he is responsible for his behavior."
B
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The nurse is assisting the physician with insertion of a new tracheostomy tube. The physician asks for the obturator. The nurse correctly hands the physician which device?
a. The guide for the tracheostomy tube to be inserted b. The scalpel used to make the tracheotomy stoma c. A single-cannula tracheostomy tube d. A cuffed tracheostomy tube
A patient in the intensive care unit begins to demonstrate agitation and picks at his clothes and intravenous lines. The nurse realizes this patient is exhibiting
1. hyperactive delirium. 2. hypoactive delirium. 3. hyperactive dementia. 4. mixed dementia.
The nurse is caring for a patient on intermittent gavage tube feedings. Over what period of time should the nurse infuse each feeding?
a. Up to 8 hours b. Up to 24 hours c. 10 to 15 minutes d. 30 to 45 minutes
The client has been diagnosed with gastroesophageal reflux (GERD) that has resulted from a relaxation of the lower esophageal sphincter (LES)
When providing instructions to assist with managing the condition, the nurse includes: Select all that apply. 1. Limit last food intake to 4 hours before bedtime. 2. Eat largest meal of the day at midday. 3. Sleep in a bed with the head elevated 6 to 8 inches. 4. Develop a daily exercise routine. 5. Include a caffeinated beverage with meals.