A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?
“It wouldn’t have mattered what you had worn.”.
“The current styles are an invitation to disaster.”.
“Never mind about blame.
That will be determined by the court.”.
The Correct Answer is A
“It wouldn’t have mattered what you had worn.” This response by a nurse is appropriate because it validates the client’s feelings and helps to reduce self-blame. It also conveys that rape is not caused by the victim’s clothing or behavior, but by the perpetrator’s violence and lack of respect.
Choice B. “The current styles are an invitation to disaster.” is wrong because it implies that the client is responsible for the rape and that she could have prevented it by dressing differently. This response is judgmental and insensitive, and may increase the client’s guilt and shame.
Choice C. “Never mind about blame.
That will be determined by the court.” is wrong because it dismisses the client’s feelings and does not address her emotional needs.
It also suggests that the nurse does not believe the client or support her. This response may make the client feel isolated and distrustful.
Choice D. “Some people don’t have very good self-control.
We have to help them all we can.” is wrong because it excuses the perpetrator’s behavior and shifts the blame to the victim.
It also implies that rape is a result of sexual desire, rather than an act of violence and domination. This response may make the client feel powerless and helpless.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Decreased sensory acuity. This is a physiological change that occurs in elderly people due to the reduced function of the sensory organs, such as the eyes, ears, nose, tongue, and skin. Elderly people may experience impaired vision, hearing loss, reduced smell and taste, and decreased touch sensitivity.
Choice A is wrong because diminished attention span is not a normal physiological change in elderly people. It may be a sign of cognitive impairment or dementia.
Choice C is wrong because the increased need for rest is not a normal physiological change in elderly people. It may be a sign of fatigue, depression, or medical conditions.
Choice D is wrong because enhanced intestinal motility is not a normal physiological change in elderly people. It may be a sign of gastrointestinal disorders or infections.
Correct Answer is A
Explanation
It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.
Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.
Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.
Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.
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