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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The client has begun playing basketball with several other clients during the past month.

Engaging in activities and social interactions can actually be a positive sign, as it suggests involvement and connection with others, which can be protective against suicide.

B. The client identifies with problems expressed by other clients.

Identifying with others' problems may indicate empathy, but it is not necessarily indicative of suicide risk on its own.

C. The client's behavior has become impulsive in the past few weeks.

Explanation: Impulsivity can be a significant risk factor for suicide. A sudden increase in impulsive behavior might indicate that the client is not thinking clearly and is acting without considering the potential consequences. Impulsivity can lead to actions that are harmful or dangerous, including suicidal behaviors.

D. The client states she wants to go home to be with her children and partner.

Expressing a desire to be with loved ones is generally not an indicator of suicide risk. In fact, having a strong support system can be protective against suicidal thoughts.

A. Dental erosion B. Hyperactive bowel sounds C. Hypertension D. Bradycardia

Correct Answer is D

Explanation

A. Dental erosion can occur due to conditions like gastroesophageal reflux disease (GERD) or frequent vomiting, but it is not a characteristic feature of anorexia nervosa.

B. Hyperactive bowel sounds are not specific to anorexia nervosa and may be seen in various gastrointestinal disorders.

C. Hypertension is not a common finding in individuals with anorexia nervosa. In fact, hypotension (low blood pressure) is more commonly observed due to decreased cardiac output related to malnutrition and electrolyte imbalances.

D. bradycardia in a client with a new diagnosis of anorexia nervosa. Bradycardia (abnormally slow heart rate) is a common cardiovascular manifestation in individuals with anorexia nervosa. It is often a result of the body's adaptive response to conserve energy due to severe malnutrition and reduced caloric intake.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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