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A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Ask the client for permission to take photographs.

Provide community sexual assault support contacts.

Document the client's verbatim statements.

Determine any physical signs of injury.

Answer and Explanation

The Correct Answer is C

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs: While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts: Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury: Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN): "Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline: "Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

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Correct Answer is A

Explanation

Choice A rationale:

In a democratic leadership style, the leader involves the group in decision-making and encourages open discussion. By asking the group for their input on resolving the bathroom issue, the nurse is demonstrating democratic leadership.

Choice B rationale:

A surrogate leadership style involves a designated individual acting as a substitute for the leader. It's not applicable in this scenario where the nurse is involving the group in decision-making.

Choice C rationale:

Laissez-faire leadership involves minimal interference and decision-making by the leader. In this scenario, the nurse is actively seeking group input, which contradicts the laissez-faire approach.

Choice D rationale:

An autocratic leadership style involves the leader making decisions without group input. Since the nurse is soliciting ideas from the group, this style doesn't apply here.

A. Plan a therapeutic diet for the client. B. Provide a structured environment for the client. C. Assess client's nutritional status. D. Request a mental health consult.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.

Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.

Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.

Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.

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A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a group therapy meeting, a client brings up a concern about the cleanliness of the bathroom. The nurse asks the group what should be done about the issue and how to resolve it. The nurse is demonstrating which type of leadership style?

Correct Answer is A

Explanation

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is C

Explanation

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