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 A
Explanation
A. Determining if the client has psychotic thinking.
Explanation: The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
Correct Answer is ["0.5"]
Explanation
To calculate the amount of ziprasidone 10 mg IM from the available concentration of 20 mg/mL, you can use the formula:
Amount (mL) = Desired Dose (mg) / Concentration (mg/mL)
Amount (mL) = 10 mg / 20 mg/mL
Amount (Ml) = 0.5 mL
Therefore, the nurse should administer 0.5 mL of ziprasidone per dose.
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