A nurse is preparing to discharge a client who was treated for sexual assault. Prior to discharge, which of the following actions should the nurse plan to take?

Provide the client with grooming supplies and a private area to bathe.

Call the client's home for someone to pick up the client

Retain the client's cell phone for evidence.

Send the client's clothes to the laundry before returning the items to the client.

Answer and Explanation

The Correct Answer is A

A. Provide the client with grooming supplies and a private area to bathe: After evidence collection and medical treatment are complete, allowing the client to bathe in privacy supports their dignity and helps restore a sense of control. This is a therapeutic and appropriate step prior to discharge.
B. Call the client's home for someone to pick up the client: Contacting someone without the client's consent could breach confidentiality and potentially endanger the client, especially if the assailant lives in the same household.
C. Retain the client's cell phone for evidence: The nurse does not have the authority to confiscate personal property like a cell phone. Evidence collection must follow legal protocols, typically involving law enforcement and forensic teams.
D. Send the client's clothes to the laundry before returning the items to the client: The client's clothing may be part of the forensic evidence. Washing or returning them before proper processing would compromise the legal chain of custody.

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Correct Answer is C

Explanation

A. Serum sodium 140 mg/dL: This is a normal sodium level and does not provide diagnostic information specific to DKA. Sodium may fluctuate in DKA but is not a defining lab value for the condition.
B. Blood urea nitrogen (BUN) 18 mg/dL: This BUN level is within normal limits. Although BUN can be elevated in DKA due to dehydration, a normal value does not support the diagnosis of DKA on its own.
C. Serum bicarbonate less than 15: A low bicarbonate level indicates metabolic acidosis, which is a key diagnostic feature of DKA. It reflects the buffering of excess ketone acids in the blood, making this a highly specific indicator.
D. Arterial blood pH 7.46: This value is slightly alkalotic and inconsistent with DKA, which is characterized by metabolic acidosis and a pH usually below 7.3. Elevated pH would suggest another acid-base disorder.

A. Maintain ventriculostomy at the correct position. B. Elevate the head of the bed to 15%. C. Maintain enteral feedings. D. Administer pain medication as needed. E. Maintain the neck in the midline position.

Correct Answer is ["A","C","D","E"]

Explanation

A. Maintain ventriculostomy at the correct position: It is critical to ensure the ventriculostomy drainage system is maintained at the prescribed height (usually at the level of the external auditory meatus) to accurately measure intracranial pressure (ICP) and safely drain cerebrospinal fluid. Incorrect positioning can lead to over- or under-drainage, which could worsen the client’s neurological status.
B. Elevate the head of the bed to 15%: Elevation of the head of the bed is recommended to promote venous drainage and reduce ICP, but 15% is too low to be effective. The recommended elevation is generally 30 degrees, not 15%, for optimal ICP management in clients with TBI. Elevating it only 15% may not sufficiently reduce intracranial pressure.
C. Maintain enteral feedings: Clients with TBI are at high risk for malnutrition due to increased metabolic demands. Early enteral nutrition supports healing, maintains gut integrity, and prevents complications such as infection or poor wound healing. It is an essential part of TBI care.
D. Administer pain medication as needed: Pain and agitation can increase ICP. Administering pain medications as needed helps control these stressors, thereby maintaining a more stable intracranial environment. Proper pain control is a key aspect of neuroprotection.
E. Maintain the neck in the midline position: Keeping the neck in a neutral midline position helps promote cerebral venous drainage and reduces the risk of increased ICP. Neck flexion or rotation can obstruct venous outflow and worsen intracranial hypertension, making this a vital positioning intervention.

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A nurse is preparing to discharge a client who was treated for sexual assault. Prior to discharge, which of the following actions should the nurse plan to take?

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