A 25-year-old female patient arrives at the emergency department after experiencing sexual violence. As a nurse, what is the highest priority intervention you should perform first?
Document all visible injuries and collect forensic evidence.
Provide the patient with privacy and ensure her immediate safety.
Contact law enforcement to report the assault.
Obtain a detailed account of the assault from the patient.
The Correct Answer is B
Choice A reason: Documentation and evidence collection are important but not the first priority. Safety and privacy must be ensured before proceeding.
Choice B reason: Providing privacy and ensuring immediate safety is the highest priority. The client has experienced trauma and needs a secure environment before any further interventions.
Choice C reason: Contacting law enforcement is necessary but should occur after the client’s immediate safety and consent are addressed.
Choice D reason: Obtaining a detailed account may retraumatize the client if done prematurely. It should follow once safety and support are established.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Telling the client to go back to their room is dismissive and does not address their emotional state.
Choice B reason: This response acknowledges the client’s feelings and invites them to express themselves. It is therapeutic, empathetic, and supportive, making it the best choice.
Choice C reason: Asking “Why” questions can sound judgmental and does not encourage open communication.
Choice D reason: Reassuring without addressing the client’s distress minimizes their feelings and is non-therapeutic.
Correct Answer is A
Explanation
Choice A reason: Setting clear, consistent limits with defined consequences is the most effective intervention for managing antisocial personality disorder. Clients with this disorder often manipulate and disregard rules, so firm boundaries and predictable consequences help maintain safety and structure.
Choice B reason: Allowing flexibility with rules undermines consistency and can reinforce manipulative behavior. Clients with antisocial traits may exploit flexibility to avoid accountability.
Choice C reason: Providing privileges immediately for good behavior can reinforce manipulation rather than genuine behavioral change. Rewards should be structured and consistent, not immediate or excessive.
Choice D reason: Encouraging guilt expression is ineffective because individuals with antisocial personality disorder typically lack remorse or guilt. This approach does not address the core issue of rule violation and manipulation.
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