Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Establishing trust with a caregiver in just five days is a challenging and unrealistic expectation for a child diagnosed with autistic spectrum disorder (ASD). Building trust takes time, especially for individuals with ASD who may struggle with social interactions and forming connections.

Choice B rationale:

Participating in a team sport with peers by day 4 might be too ambitious for a child with ASD. Children with ASD often require gradual exposure and support to engage in social activities, and such rapid participation might lead to anxiety and discomfort.

Choice C rationale:

While communication goals are important for children with ASD, expecting them to communicate all needs verbally by discharge might not be realistic. Many children with ASD use alternative forms of communication, such as gestures or assistive devices, which should also be considered as valid modes of expression.

Choice D rationale:

The realistic outcome for a child diagnosed with ASD is that they will perform most self-care tasks independently. ASD often affects social and communication skills, but children can learn and develop the ability to manage self-care tasks with proper support and intervention. This outcome aligns with the developmental trajectory of children with ASD.

A. Shorten a reading activity when the child appears to become frustrated. B. Introduce some humor during interactions with the child. C. Redirect with physical activities when the child's disruptive behavior begins. D. Explain to the child the importance of picking up crayons when thrown on the floor. E. Place the child in a vest restraint when disruptive behavior occurs.

Correct Answer is ["A","B","C","D"]

Explanation

The correct answer is: A, B, C, D.

Choice A reason: Shortening a reading activity when the child appears to become frustrated can help prevent the child from becoming overwhelmed and acting out. This is a common strategy used in managing children with conduct disorders.

Choice B reason: Introducing humor during interactions with the child can help build rapport and make the child feel more comfortable. It can also serve as a positive distraction and reduce tension.

Choice C reason: Redirecting with physical activities when the child’s disruptive behavior begins can serve as a healthy outlet for the child’s energy and frustrations. Physical activities can also help improve the child’s mood and reduce disruptive behaviors.

Choice D reason: Explaining to the child the importance of picking up crayons when thrown on the floor can help teach the child responsibility and respect for their environment. This can also be a part of behavioral therapy where the child learns about consequences of their actions.

Choice E reason: Placing the child in a vest restraint when disruptive behavior occurs is not recommended. Using physical restraints can be traumatizing and should only be used as a last resort when the child’s behavior poses a risk to themselves or others. It’s always better to use de-escalation techniques and positive reinforcement to manage disruptive behavior.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is reviewing the records of a child diagnosed with autistic spectrum disorder (ASD). Which of the following client outcomes should the nurse recognize as realistic for a client diagnosed with ASD?

Correct Answer is D

Explanation

A nurse is caring for a school-age child who has a history of conduct disorder. Which of the following actions should the nurse take while caring for the child? (Select all that apply.).

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is planning a unit orientation for a newly admitted client diagnosed with severe depression. Which of the following should be the nurse's approach?

A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

A school nurse is speaking to the mother of a 16-year-old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

A nurse educator is discussing community mental health with a group of nursing students. Based on the public health model, which of the following statements made by one of the students indicates correct information about primary prevention?

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find that I have cancer." Which of the following should be the appropriate response by the nurse?

A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate that the client is experiencing maladaptive grief?