A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient's underclothes. Priority actions by the nurse should focus on:

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Question 1 of 5

A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient's underclothes. Priority actions by the nurse should focus on:

Correct Answer: B

Rationale: The correct answer is B: Maintaining the patient's airway. This is the priority action because the patient is unconscious and airway patency is crucial for survival. Preserving rape evidence (A) can be important, but the patient's immediate health takes precedence. Obtaining a description of the rape (C) can wait until the patient's condition stabilizes. Determining what drugs were ingested (D) is important but secondary to ensuring the patient can breathe.

Question 2 of 5

The nurse is planning care for a battered woman who has mentioned, 'Someday I'll have to leave him.' Which outcome should the nurse include in the plan of care for this client?

Correct Answer: D

Rationale: The correct answer is D: Client will verbalize awareness of the dangerousness of her situation. This outcome is crucial as it indicates the client's understanding of the risks involved in her current situation. By verbalizing awareness, the client is acknowledging the potential harm and taking a significant step towards recognizing the need for change. This outcome lays the foundation for further interventions and support. Choice A is incorrect because setting a specific timeline for leaving may not be feasible or safe for the client. Choice B is incorrect as feeling relaxed does not necessarily address the underlying issue of abuse. Choice C is incorrect as feeling strong does not necessarily equate to recognizing the dangers of the situation. The focus should be on increasing awareness and empowering the client to make informed decisions.

Question 3 of 5

The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse assesses the client's stage of Alzheimer's disease as stage:

Correct Answer: B

Rationale: The correct answer is B (stage 2) because the client is exhibiting symptoms of moderate Alzheimer's disease, such as paranoia and delusions. In stage 2, cognitive decline becomes more noticeable, leading to memory loss, confusion, and behavioral changes. The client's accusations and false beliefs indicate a decline in reality orientation, which is characteristic of stage 2. Choices A, C, and D are incorrect because stage 1 is characterized by mild cognitive decline, stage 3 by severe cognitive decline, and stage 4 by very severe cognitive decline.

Question 4 of 5

A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:

Correct Answer: C

Rationale: The correct answer is C: Delirium. Delirium is characterized by acute and fluctuating changes in cognition, attention, and awareness. The client's sudden onset of symptoms, including disorientation, confusion, agitation, restlessness, impaired memory, delusions, and misinterpretations of surroundings, align with the hallmark features of delirium. The nurse needs to further assess the client for delirium to determine the underlying cause and provide appropriate interventions promptly. Incorrect choices: A: Dementia - Dementia is a chronic, progressive condition characterized by gradual cognitive decline. The client's acute onset of symptoms is not consistent with dementia. B: Depression - Depression typically presents with persistent feelings of sadness, hopelessness, and loss of interest, which are different from the acute and fluctuating cognitive changes seen in delirium. D: Amnesia - Amnesia refers to memory loss, which is only one aspect of the client's presentation. Delirium involves a broader range of cognitive

Question 5 of 5

The nurse is answering questions from a client and his family regarding a recent diagnosis of Alzheimer's disease. The client asks how effective medication is in treating the disease. What is the nurse's best response?

Correct Answer: C

Rationale: The correct answer is C because medications for Alzheimer's disease, such as cholinesterase inhibitors and memantine, have been found to improve thinking abilities, behavior, and daily functioning in some clients. These medications can help manage symptoms and slow down the progression of the disease. Option A is incorrect because while there is no cure for Alzheimer's disease, there are treatments available. Option B is incorrect as medications have shown some efficacy in managing symptoms. Option D is incorrect as there is limited scientific evidence to support the effectiveness of alternative therapies compared to prescription medications for Alzheimer's disease.

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