A frightened young woman calls the emergency department and tearfully tells the nurse, "I've been raped! Please help me!" Before telling the client what to do, the nurse needs to know:
A) If she was injured, was in a safe place, and had transportation available
B) If she knew her assailant, knew her location, and had notified the police
C) If she has insurance, if she could get to the hospital by herself, and if pregnancy is a possibility
D) If she had bathed, douched, or changed clothes
A
Feedback: If the client is injured, she may need immediate medical attention; if she is in a safe place, she can talk to the nurse on the phone. All other questions can wait until the client's safety is ensured.
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A patient who has been pacing rapidly for the past hour cannot immediately be located on the unit. When he is found, he is in his closet, rocking back and forth rapidly and talking rapidly to himself
When staff approach, he only seems to notice them momentarily, then leaves his room and begins running up and down the hallway. Which of the following interventions should be attempted at this point? a. "I want you to breathe deeply as I do, in slowly, now hold it, now breathe out.". b. "I have some medicine that will calm you; would you like it by pill or in a shot?" c. In a calm but direct voice say: "Stop running. I will stay with you. Walk with me.". d. Gather a show of force and say: "You need to come with us now to seclusion.".
The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for toddlers?
1. Assign the same nurse to the toddler as much as possible. 2. Let the child listen to an audiotape of the mother's voice. 3. Place a picture of the family at the bedside. 4. Encourage a parent to stay with the child.
The nurse is caring for an abused mother in the postpartum department. The patient is afraid to go home, but has no money to do anything else. What can the nurse do to assist this individual and her baby?
1. Work with social services to have the patient and her baby go to a safe place, complete paperwork to obtain financial assistance, and obtain some temporary assistance. 2. Explain that she will have to go home at this time, but provide her with paperwork to complete to obtain assistance. 3. Offer to have her partner come in and attend a counseling session with her. 4. Suggest that once she gets home, she should pursue getting a restraining order against her abuser.
A pregnant patient asks, "What's the difference between the true pelvis and the false pelvis?" The nurse's best response is:
1. "The true pelvis doesn't affect fetal passage during labor and childbirth." 2. "The false pelvis consists of the inlet, the pelvic cavity, and the outlet." 3. "The true pelvis helps direct the presenting fetal part into the false pelvis." 4. "The false pelvis helps support the weight of the pregnant uterus."