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 A

Explanation

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

A. Encouraging client feedback about satisfaction with the facility experience B. Explaining unit rules and policies regarding unacceptable behaviors C. Supporting the client's wish to refuse prescribed medications D. Making sure the client understands expectations for client participation

Correct Answer is C

Explanation

Encouraging client feedback about their satisfaction with the facility experience is related to communication and patient-centered care, but it's not directly addressing the client's autonomy in making decisions about their own care or treatment.

B) Explaining unit rules and policies regarding unacceptable behaviors:

Explaining unit rules and policies is important for maintaining a safe and therapeutic environment, but it's more about providing information and setting expectations rather than addressing the client's autonomy.

C) Supporting the client's wish to refuse prescribed medications.

Explanation:

Autonomy is the ethical principle that emphasizes an individual's right to make decisions about their own care and treatment. In the context of healthcare, respecting autonomy means that healthcare professionals should honor a patient's decisions as long as they are informed and capable of making those decisions. By supporting the client's wish to refuse prescribed medications, the nurse is respecting the client's autonomy and allowing them to have control over their own treatment decisions.

D) Making sure the client understands expectations for client participation:

Ensuring that the client understands expectations for participation is important for collaboration in their care, but it's not directly related to the client's autonomous decision-making about their treatment.

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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?

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