A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
Discuss self-defense techniques with the client.
Give the client a bed bath prior to physical examination.
Inform the client photographs of injuries are required for a police report.
Ask the client to describe the situation.
The Correct Answer is D
A. Discuss self-defense techniques with the client: Incorrect
While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.
B. Give the client a bed bath prior to physical examination: Incorrect
In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.
C. Inform the client photographs of injuries are required for a police report: Correct
Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.
D. Ask the client to describe the situation: Correct
It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "How long has this been going on?":
While this question is important for gathering more information, it may come across as more investigative or less empathetic at this initial stage of the conversation.
B. "Why do you think you are so anxious?":
While it's important to understand the client's perspective, this response might come across as confrontational or judgmental. It's better to create an open and non-judgmental environment for the client to share their feelings.
C. "Have you talked to your parents about this yet?":
This response assumes that the client has parents to talk to and may not be relevant for all clients. It's also important to establish trust and rapport with the client before asking about their support network.
D. "It sounds like you're having a difficult time.":
This response is empathetic and validating. It acknowledges the client's feelings without making assumptions or demands, creating a supportive environment for further discussion.
Correct Answer is ["2"]
Explanation
The nurse should administer 2 tablets of olanzapine 10 mg orally-disintegrating tablets per dose.
Here's the calculation:
20 mg (desired dose) ÷ 10 mg (strength of each tablet) = 2 tablets
So, the nurse should administer 2 tablets of olanzapine 10 mg orally-disintegrating tablets per dose.
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