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 C
Explanation
A. Antidepressants usually take several weeks to start taking effect, so the statement "I can be on my antidepressant taking three to five days to be effective" is not correct.
B. While positive thinking can play a role in managing mood, depression is a complex disorder that often requires more than just positive thoughts to treat. The statement "I can cure my depression by thinking positive thoughts" oversimplifies the condition.
C. "I will attend psychotherapy to help manage my depression."
Explanation:
Depressive disorders, including major depression, are complex conditions that typically require a multifaceted approach to treatment. Psychotherapy, also known as talk therapy, is an important component of treating depression. It involves working with a trained therapist to explore and address the thoughts, feelings, and behaviors contributing to the depression. Psychotherapy can help individuals develop coping strategies, improve problem-solving skills, and gain insight into their condition.
D. Depression is not something that can be simply chosen to be stopped voluntarily. It is a mental health disorder that often requires professional treatment and support. The statement "I need to make a voluntary choice to stop feeling depressed" does not accurately capture the nature of depression.
Correct Answer is B
Explanation
This action might be premature. MAOIs (Monoamine Oxidase Inhibitors) are a class of antidepressants with specific dietary and medication interactions. They are typically considered when other classes of antidepressants have not been effective. It's important to exhaust other options before considering a switch to MAOIs.
B. Explain that antidepressants often take several weeks to be fully effective:
Explanation: Correct Answer. This is an appropriate response. Antidepressants, including citalopram, can take several weeks to show their full therapeutic effects. It's common for some symptoms to improve before others. Educating the client about the delayed onset of action is important to manage their expectations.
C. Tell the client that the provider will need to change citalopram to a different medication:
Explanation: It might be too early to consider changing the medication after just two weeks, especially since the client reports an improved appetite. Changes in dosage or medication should ideally be discussed with the provider after an adequate trial period.
D. Recommend a sleep study be done on the client:
Explanation: While sleep problems can be associated with depression, it might not be the most appropriate next step based solely on the information provided. It's more important to address the ongoing depressive symptoms before focusing solely on sleep.
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