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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: "I'm hearing that you are concerned that it might turn out that you have cancer."
Choice A rationale:
Dismissing the client's concerns and saying there's no reason to worry is not empathetic. It invalidates the client's feelings and does not address their anxiety.
Choice B rationale:
While discussing concerns with the provider is important, it's not the most therapeutic initial response. The nurse should engage with the client's feelings before suggesting actions.
Choice C rationale:
This is the correct choice. Reflecting the client's concerns back to them shows empathy and encourages them to express their feelings. This approach opens up communication and allows the nurse to provide support.
Choice D rationale:
Asking the client why they think they might have cancer could come across as confrontational and dismissive. The focus should be on understanding their feelings rather than challenging their thoughts.
Correct Answer is D
Explanation
Choice A rationale:
The client taking an overdose of the medication is unlikely to be the cause of the symptoms. Disulfiram (Antabuse) is a medication used to treat alcohol dependence by causing adverse effects when alcohol is consumed. However, an overdose would not result in severe nausea and vomiting as described.
Choice B rationale:
Experiencing common side effects of the medication is a possibility, but severe nausea and vomiting are not typical side effects of disulfiram. The medication's primary purpose is to induce unpleasant effects when alcohol is consumed, not to cause severe gastrointestinal symptoms.
Choice C rationale:
Demonstrating an allergic response to the medication could potentially cause various symptoms, but severe nausea and vomiting are not commonly associated with allergies to disulfiram. Allergic reactions often manifest as skin rashes, itching, and respiratory symptoms, which are not described in this scenario.
Choice D rationale:
The correct choice. Disulfiram works by inhibiting alcohol metabolism, leading to the accumulation of acetaldehyde, a toxic substance, when alcohol is consumed. This buildup of acetaldehyde results in unpleasant symptoms like severe nausea, vomiting, headache, and flushing. Since the client has recently started taking disulfiram and reports experiencing severe nausea and vomiting after discontinuing the medication, it is most likely that the client consumed alcohol while taking the medication, triggering the adverse reaction.
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