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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

The correct answer is choice A: "Assess the client's need for assistance with ADLS."

Choice A rationale:

Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.

Choice B rationale:

Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.

Choice C rationale:

Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.

Choice D rationale:

Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.

A. The client responds to questions with disorganized speech. B. The client reports that voices are telling him to write a novel. C. The client's spouse reports that the client has recently gained weight. D. The client is dressed in all black.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. Clients may exhibit pressured speech, tangentiality, and flight of ideas, reflecting the heightened energy and cognitive disruptions associated with manic episodes.

Choice B rationale: Reporting auditory hallucinations, such as voices telling the client to write a novel, is more indicative of a psychotic disorder rather than acute mania in bipolar disorder. Mania typically involves elevated mood and activity levels, not hallucinations.

Choice C rationale: Weight gain reported by the spouse is not specific to acute mania. While changes in appetite and weight can occur in bipolar disorder, they are not defining features of manic episodes, which are characterized by heightened mood and activity.

Choice D rationale: Being dressed in all black does not specifically indicate acute mania. Mania is characterized by mood disturbances and increased activity levels rather than specific choices in clothing color, which can vary widely among individuals.

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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?

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