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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cyanosis: Cyanosis is a late sign of hypoxemia, not specifically hypercapnia. It indicates poor oxygenation of tissues but does not directly reflect elevated carbon dioxide levels in the blood.
B. Arrhythmias: Arrhythmias may occur in respiratory failure due to hypoxemia or acid-base disturbances. However, they are not the most specific indicator of severe hypercapnia and can result from a range of metabolic or cardiac causes.
C. Asterixis: Asterixis, or "flapping tremor," is a neurologic manifestation of severe hypercapnia and altered mental status. It results from elevated CO₂ levels affecting brain function and is often seen in CO₂ narcosis or advanced respiratory failure.
D. Tachycardia: Tachycardia is a common compensatory response to hypoxia or hypercapnia, but it is nonspecific. It can be seen in many conditions and is not a definitive sign of severe carbon dioxide retention.
Correct Answer is A
Explanation
A. Tachycardia: Elevated T3 and T4 levels with suppressed TSH indicate hyperthyroidism, which increases metabolic rate and sympathetic nervous system activity. This often results in tachycardia due to increased cardiac demand and heightened sensitivity to catecholamines.
B. Decreased body temperature: Hyperthyroidism typically causes increased heat production and heat intolerance. Clients often feel warm or overheated, not cold, so a drop in body temperature would be unexpected.
C. Slow respiratory rate: Increased metabolism usually raises oxygen demand, leading to a normal or increased respiratory rate. A slow respiratory rate is not characteristic of hyperthyroid states.
D. Hypotension: Hyperthyroidism often causes systolic hypertension due to increased cardiac output. While some clients may experience normal blood pressure, persistent hypotension is not a common finding.
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.