D455 Professional Nursing Role Transition - Set 4 - Part 3

Correct Answer: Beginning with less sensitive questions first

Option b is correct because starting with less threatening questions builds rapport and trust before addressing the most difficult topics. This graduated approach reduces defensive responses and increases the likelihood of honest disclosure about traumatic abuse experiences. Option a is incorrect because immediately asking about abusive events before establishing rapport causes defensive shutdown and withdrawal. Clients who feel pressured to disclose traumatic information without adequate trust-building are less likely to share honestly and completely. Option c is incorrect because sharing personal values about abuse situations violates professional boundaries and introduces the nurse's bias into the therapeutic interaction. The assessment should focus on the client's experience without the influence of the nurse's personal moral perspectives. Option d is incorrect because intentionally vague questions fail to gather specific assessment information needed for safety plan

Correct Answer: Exploring the client's readiness to discuss it

Option a is correct because assessing readiness to discuss the situation respects client autonomy while evaluating where the client is in the stages of change. This therapeutic approach maintains the alliance and allows the nurse to provide appropriate support at the client's pace. Option b is incorrect because immediately contacting law enforcement without the client's consent undermines autonomy and trust in the therapeutic relationship unless there is imminent danger. Assessing readiness and supporting the client's decision-making process should precede external reporting actions. Option c is incorrect because determining exact abuse frequency is an assessment detail that should follow initial therapeutic engagement. Pressing for specific incident counts before the client is ready to discuss the situation can feel interrogative and damage the therapeutic relationship. Option d is incorrect because shifting focus to the abusive partner's treatment needs before ass

Correct Answer: Checking the client's level of consciousness

Option d is correct because assessing level of consciousness immediately determines the severity of blood loss and hemorrhagic shock, which guides the urgency and sequence of all subsequent interventions including wound management, fluid resuscitation, and emergency activation. Option a is incorrect because although applying pressure to bleeding wounds is a critical intervention, it should follow the initial consciousness assessment. The client's level of responsiveness determines whether the situation requires immediate life support measures beyond wound management. Option b is incorrect because activating the emergency response team is an important early action but should follow the initial consciousness assessment. Knowing the client's responsiveness level provides critical information to communicate when activating the emergency response system. Option c is incorrect because estimating blood volume loss is part of the ongoing assessment but is not the very first action. D

Correct Answer: The unit's registered nurse with full assessment skills

Option c is correct because continuous safety assessment, suicide risk evaluation, and crisis intervention require the advanced clinical judgment of a registered nurse. Suicidal clients need ongoing assessment skills that exceed the scope of other personnel categories. Option a is incorrect because unlicensed assistive personnel cannot perform the continuous safety assessment and clinical judgment required for suicidal clients. Suicide risk evaluation involves ongoing interpretation of verbal and behavioral cues that exceed the training and scope of assistive personnel. Option b is incorrect because a float pool practical nurse from another unit lacks familiarity with the unit protocols and the advanced assessment skills needed for ongoing suicide risk evaluation. The registered nurse's comprehensive assessment capability is essential for this high-risk client. Option d is incorrect because a nursing student under faculty supervision requires oversight themselves and should not be

Correct Answer: Physical abuse requiring further assessment

Option b is correct because bruises in different healing stages with inconsistent explanations and behavioral indicators like eye contact avoidance are classic warning signs of physical abuse. These findings require further assessment, documentation, and appropriate reporting. Option a is incorrect because accidental injuries typically produce consistent explanations matching the physical findings, and bruises would generally be in the same healing stage. Multiple bruises at different stages with vague explanations contradict normal accidental injury patterns. Option c is incorrect because while self-inflicted injuries can occur with mental illness, the inconsistent explanations and behavioral avoidance patterns more strongly suggest external abuse. Self-harm injuries typically present in accessible locations with different distribution patterns. Option d is incorrect because while some medications cause easy bruising, this would not explain the client's behavioral indicators incl

Correct Answer: Head of bed elevated to thirty degrees neutral

Option a is correct because elevating the head of bed to thirty degrees with head and neck in neutral alignment promotes venous drainage from the brain and reduces intracranial pressure while maintaining adequate cerebral perfusion during the acute stroke evaluation. Option b is incorrect because the completely flat supine position increases intracranial pressure by impeding venous drainage from the brain. Stroke clients require head elevation to promote cerebral venous outflow and reduce the risk of worsening neurological damage. Option c is incorrect because Trendelenburg position with feet elevated above the head dramatically increases intracranial pressure by directing blood flow toward the brain. This position is absolutely contraindicated in stroke clients and could worsen cerebral edema and hemorrhage. Option d is incorrect because positioning the client on the affected right side may impair circulation to already compromised tissues and is not the recommended acute stroke posit

Correct Answer: Stopping the feeding and assessing swallow reflex

Option d is correct because stroke clients with facial paralysis are at extremely high risk for aspiration. Giving fluids without confirming intact swallow function could cause aspiration pneumonia or airway obstruction. The nurse must immediately stop the attempt and assess swallowing. Option a is incorrect because instructing about fluid thickening assumes the client can safely swallow at all, which has not been assessed. The swallow reflex must be evaluated before any oral intake decisions including fluid consistency modifications are made. Option b is incorrect because documentation is important but must follow the immediate safety intervention. The priority is preventing potential aspiration by stopping the water intake and assessing swallow function before addressing any documentation or communication needs. Option c is incorrect because while head elevation supports safer swallowing, it does not replace the need to first stop the feeding attempt and formally assess the swallow r

Correct Answer: Providing a pictorial communication board

Option c is correct because left cerebral hemisphere damage causes expressive aphasia, impairing the client's ability to communicate verbally. A pictorial communication board provides an alternative method for expressing needs and reduces frustration from inability to speak. Option a is incorrect because the bedside commode should be placed on the left unaffected side to promote safe independent transfers. Placing equipment on the right hemiplegic side forces the client to use the impaired side, increasing fall and injury risk. Option b is incorrect because relying exclusively on verbal communication is ineffective for a client with expressive aphasia from left hemisphere damage. The client cannot produce speech normally and requires alternative communication methods such as picture boards or written materials. Option d is incorrect because positioning items toward the impaired right side forces the client to reach across the body with a hemiplegic extremity, increasing frustratio

Correct Answer: Impaired swallowing reflex function

Option b is correct because impaired swallowing reflex is the primary risk factor for aspiration in stroke clients. Facial paralysis and cranial nerve damage from stroke can abolish protective swallow mechanisms, making oral intake potentially life-threatening without formal assessment. Option a is incorrect because elevated blood pressure is a common stroke finding requiring management but does not directly indicate aspiration risk. Hypertension affects cerebral perfusion and hemorrhage risk rather than the mechanical ability to safely swallow food and fluids. Option c is incorrect because the presence of intravenous access is a therapeutic intervention for fluid and medication delivery that does not indicate aspiration risk. IV access is standard stroke care and has no relationship to the client's swallowing safety status. Option d is incorrect because mild headache with visual disturbances may indicate neurological changes but does not directly assess aspiration risk. Swallow f

Correct Answer: Loss of motor control from brain hemisphere damage

Option d is correct because left cerebral hemisphere damage causes contralateral right-sided hemiplegia with loss of voluntary motor control. The affected extremities cannot support or protect themselves during repositioning and require external support to prevent injury. Option a is incorrect because right-sided hemiplegia from left hemisphere stroke typically involves decreased rather than increased sensation on the affected side. The need for support stems from motor control loss rather than heightened pain sensitivity during repositioning. Option b is incorrect because the need to support the right side during repositioning results from permanent motor pathway disruption rather than temporary muscle spasms. Hemiplegia reflects lost voluntary control requiring ongoing physical support throughout recovery and rehabilitation. Option c is incorrect because right-sided hemiplegia involves loss of voluntary movement rather than excessive movement requiring restraint. The affected side la