A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

A. Contact children and youth services. There is no indication that the client is a minor. Mandatory reporting to child protective services applies to minors, but in the case of an adult client, reporting sexual assault is the client’s decision unless required by law (such as in cases involving incapacitated individuals or threats to public safety).
B. Administer sexually transmitted infection prophylaxis. Clients who have experienced sexual assault should be offered prophylactic treatment for sexually transmitted infections (STIs), including chlamydia, gonorrhea, and trichomoniasis, in accordance with CDC guidelines. Post-exposure prophylaxis for HIV may also be considered based on risk factors.
C. Provide resources to the client for the local Alcoholics Anonymous chapter. The client reports social drinking but has not indicated problematic alcohol use or a desire for treatment. Providing unsolicited resources for Alcoholics Anonymous may not be appropriate in this situation.
D. Maintain a safe and private environment for the client. Ensuring privacy and a safe space is essential for clients who have experienced trauma. The nurse should provide emotional support, minimize interruptions, and allow the client to make decisions regarding care.
E. Request a consult for case management. Case management services can assist with legal considerations, follow-up care, counseling referrals, and safety planning. The nurse should initiate a referral to support the client’s needs.
F. Provide resources for local support services. Sexual assault survivors should receive information about crisis hotlines, advocacy groups, counseling services, and other community resources that can offer emotional and legal support.

A. Initiate droplet precautions. Respiratory syncytial virus (RSV) is primarily transmitted through respiratory secretions, requiring contact and droplet precautions to prevent the spread. Isolation measures, including wearing masks and gowns, help protect healthcare workers and other patients.
B. Administer fluconazole to the preschooler. Fluconazole is an antifungal medication, which is not effective against RSV, a viral infection. Treatment for RSV is mainly supportive, focusing on airway management, hydration, and oxygen therapy as needed.
C. Monitor the preschooler's urine for protein. Proteinuria is associated with kidney conditions such as nephrotic syndrome, not RSV. RSV primarily affects the respiratory system, causing bronchiolitis and increased mucus production rather than kidney involvement.
D. Request an x-ray of the preschooler's neck. A neck x-ray is typically used to evaluate airway obstruction from conditions like epiglottitis. RSV affects the lower respiratory tract, leading to bronchiolitis, and does not usually require imaging unless complications arise.