A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library.
Which intervention is most crucial for the nurse to implement?
Pay close attention to the client’s account of the event.
Report the incident to the university’s security department.
Prevent the client from showering until all evidence is collected.
Ascertain the client’s personal reaction to the reported rape.
The Correct Answer is C
Choice A rationale
Paying close attention to the client’s account of the event is important, but it is not the most crucial intervention. The nurse should listen empathetically and nonjudgmentally to the client’s account, but this should not take precedence over ensuring the client’s physical well- being and preserving evidence.
Choice B rationale
Reporting the incident to the university’s security department is not the most crucial intervention. While it is important to report the incident to the appropriate authorities, the nurse’s primary responsibility is to the client. Ensuring the client’s physical well-being and preserving evidence should take precedence.
Choice C rationale
Preventing the client from showering until all evidence is collected is the most crucial intervention. Showering can destroy valuable physical evidence that can be used in the investigation and prosecution of the crime.
Choice D rationale
Ascertaining the client’s personal reaction to the reported rape is important, but it is not the most crucial intervention. The nurse should provide emotional support and refer the client to counseling services, but this should not take precedence over ensuring the client’s physical well-being and preserving evidence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While abdominal cramping can be a symptom of gastritis, it is not typically a sign of a serious complication that would require immediate medical attention.
Choice B rationale
Bruising of the skin is not typically associated with gastritis. If the client notices unexplained bruising, they should report it, but it is not the most critical symptom to watch for.
Choice C rationale
A low-grade fever can be a symptom of gastritis, but it is not typically a sign of a serious complication. The client should monitor their temperature, but it is not the most critical symptom to watch for.
Choice D rationale
Bloody emesis can be a sign of a serious complication of gastritis, such as a bleeding ulcer. If the client notices bloody or coffee-ground emesis, they should seek medical attention immediately.
Correct Answer is B
Explanation
Choice A rationale
Reinforcing the connection of the chest tube to the container with tape is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the connection between the chest tube and the container is loose, but it does not address the immediate need of the client.
Choice B rationale
If a client with a chest tube becomes suddenly short of breath and anxious, the nurse should immediately clamp the chest tube with a plastic clamp. This is because the chest tube might have been disconnected from the water seal chamber, and clamping the tube can prevent air from entering the pleural space and causing a tension pneumothorax.
Choice C rationale
Applying an occlusive dressing over the site of the chest tube is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the chest tube is accidentally removed, but it does not address the immediate need of the client.
Choice D rationale
Ensuring that the chest tubing is neither kinked nor hanging low is an important part of the ongoing care for a client with a chest tube, but it is not the immediate action to be taken when a client becomes suddenly short of breath and anxious.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.