A raped client answers a nurse's questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this client's responses?
1. The client may be lying about the incident.
2. The client may be experiencing a silent rape reaction.
3. The client may be demonstrating a controlled response pattern.
4. The client may be having a compounded rape reaction.
3
Rationale: This client is most likely demonstrating a controlled response pattern. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness, and tension.
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Which intervention addresses a guiding principle for creating an elder-friendly acute care facility?
a. Each bathroom is equipped with safety bars and low wattage lighting b. A client is asked when they would prefer to bathe; morning, afternoon or evening c. Televisions include a closed captioned function to assist the hearing impaired d. Families are encouraged to bring foods from home that are allowed on the individual's diet
The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant requires intervention by the registered nurse?
a. Using an alcohol-based hand rub after caring for a client with diarrhea b. Washing hands for 20 seconds using warm water and friction c. Cleaning especially carefully under fin-gernails and around a wedding band d. Using chlorhexidine for handwashing when caring for clients on neutropenic precautions
The nurse is converting a client's continuous IV infusion to a saline lock. Which of following is a recommended guideline for this procedure?
A) Stop the infusion and unclamp the tube to allow air to flow out of the line. B) Replace the primary IV tubing with a PICC line. C) Flush the lock with 2 to 3 mL of heparin every 4 hours to prevent clogging. D) Flush the lock with 2 to 3 mL of saline every 8 hours or as ordered.
How can schools determine what their school health education priorities should include?
a. Provide opportunities for students to practice decision-making skills b. Choose priorities according to which behaviors lead to avoidable problems c. Make priorities consistent with the six topics identified by Healthy People 2020 d. Determine priorities by the education and expertise of the local school nurse e. Select priorities according to parent and student interests f. Decide on priorities based on whatever funding sources are willing to fund