A nurse is assisting a sexual assault nurse examiner (SANE) with the care of a client who has experienced sexual assault. The nurse should identify which of the following as the role of the SANE?

A. Demand that the client remove hidden objects from their clothing prior to being weighed. While it is important to ensure accurate weight measurement, demanding removal of hidden objects may create a confrontational atmosphere and increase anxiety for the client. A more supportive approach is beneficial in this setting.
B. Invite the client to predict their weight beforehand. Encouraging clients to predict their weight can help engage them in the process and promote a sense of control. This approach may also facilitate a therapeutic conversation about their feelings regarding weight and body image.
C. Monitor for any extra fluids the client may have consumed prior to being weighed. While monitoring fluid intake is important in the overall care of clients with eating disorders, it is not a standard practice to monitor this immediately before weighing unless there is a specific concern about fluid retention or overhydration.
D. Weigh the client each day after their evening meal. Weighing clients daily can contribute to anxiety and unhealthy focus on weight. It is generally more effective to establish a consistent weighing schedule that minimizes distress, such as weekly or bi-weekly measurements, rather than immediately following meals.

A. Shuffling walk. A shuffling walk is typically associated with parkinsonism or other movement disorders, which may occur with antipsychotic medications, but the specific symptom of restlessness more directly relates to other conditions.
B. Suicidal ideation. While monitoring for suicidal ideation is important in any client with psychosis, it is not specifically associated with the restlessness that the client reports in relation to chlorpromazine use.
C. Abnormal movements of the tongue and face. Abnormal movements of the tongue and face are more characteristic of tardive dyskinesia, which develops over a longer period of treatment. The acute restlessness the client is experiencing is more closely aligned with akathisia, a side effect of antipsychotic medications.
D. Oculogyric crisis. This condition involves involuntary upward eye movement and can occur as an acute dystonic reaction to antipsychotic medications like chlorpromazine. Given the client's report of restlessness, the nurse should monitor for this adverse effect, as it is more likely to manifest in the context of acute medication side effects.