A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

"The police will want to interview you."

"I will call your spouse."

"We'll have to take photographs of those wounds."

"You are safe now."

Answer and Explanation

The Correct Answer is D

D. This statement prioritizes the client's immediate emotional needs by providing reassurance, validation, and a sense of safety in a traumatic situation. It acknowledges the client's distress and communicates empathy and support, which are essential for building trust and rapport and facilitating the client's emotional healing process.
A. The client may feel overwhelmed by the prospect of speaking to the police at that moment, and it may not be the most therapeutic statement to prioritize.
B. Contacting the client's spouse may provide emotional support and assistance, but it may not be the priority therapeutic statement in this situation.
C. The client may already be feeling vulnerable and exposed, and discussing the need for photographs may exacerbate feelings of distress or discomfort.

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Correct Answer is C

Explanation

C. Acceptance and trust create a sense of safety and security for the client within the therapeutic relationship. When the client feels accepted and valued by the nurse, they are more likely to feel comfortable opening up and engaging in the therapeutic process.
A. Establishing a therapeutic alliance provides a safe and supportive environment for the client to express their feelings without fear of judgment or rejection. However, therapeutic alliance goes beyond this.
B. Therapeutic activities can indeed provide an outlet for tension and stress but the establishment of a therapeutic alliance goes beyond engaging in specific activities.
D. Focusing on positive behaviors and strengths can contribute to building self-esteem. However, the establishment of a therapeutic alliance involves more than just focusing on behaviors.

A. Request a psychiatric evaluation for the client B. Interview the client alone and assess for abuse C. Provide the daughter and client with nutritional counseling D. Take the history from the daughter because of the client's confusion

Correct Answer is B

Explanation

B. Given the client's confusion and the daughter's behavior of constantly interrupting and not allowing the client to answer, there may be concerns about elder abuse or neglect. It's essential to create a safe and private environment for the client to speak freely without interference.
A. The client's confusion and reluctance to speak may raise concerns about their mental status. However, requesting a psychiatric evaluation is not the priority in this scenario. The client's immediate needs, including hydration, nutrition, and safety, should be addressed first.
C. Addressing malnutrition is important but providing nutritional counseling is not the priority in this scenario. The client's severe dehydration and potential abuse or neglect take precedence over nutritional concerns.
D. Obtaining information from the daughter may be helpful but it should not be the sole source of information, especially if there are concerns about the daughter's behavior and potential interference with the client's ability to communicate.

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A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse working with a teen, who has a history of being moody and withdrawn, will make the establishment of a therapeutic alliance a priority because:

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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