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 A
Explanation
Choice A rationale
Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention.
Choice B rationale
Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first.
Choice D rationale
Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.
Correct Answer is ["D","E","F"]
Explanation
Choice A rationale
While it’s important to honor commitments, it’s also crucial to recognize when the caregiving role becomes too stressful or burdensome. Insisting on keeping a promise despite significant stress can lead to caregiver burnout.
Choice B rationale
This statement is not accurate. Moving a loved one into a care facility is sometimes the best decision for both the caregiver and the care recipient. It does not reflect a lack of love, but rather a recognition of the need for professional help.
Choice C rationale
This statement is not accurate. Caring for an adult, especially one with health issues, can be more challenging than raising a child in many ways.
Choice D rationale
Involving the care recipient in the decision-making process can help maintain their autonomy and dignity. It can also make the caregiving process more manageable.
Choice E rationale
It’s normal to have mixed feelings about a loved one for whom you’re providing care. Acknowledging these feelings can be an important step in managing caregiver stress.
Choice F rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.
Choice G rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.
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.