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. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the first priority. The primary concern after a traumatic fall is to rule out any life-threatening conditions, such as intracranial bleeding or fractures, which require diagnostic imaging before administering pain relief.
B. Insert an indwelling urinary catheter to monitor urine output: Inserting a catheter may be necessary later, but the first step should be assessing for any immediate life-threatening injuries or complications resulting from the fall, which can be done through imaging studies.
C. Prepare for a STAT non-contrast CT scan: The first priority after a traumatic fall, especially if there is a concern about head injury or internal bleeding, is to assess for any potential life-threatening conditions through a non-contrast CT scan. This helps identify fractures, bleeding, or brain injuries that need immediate attention.
D. Perform a thorough health history: While gathering a health history is important, it should come after ensuring that any potential life-threatening injuries have been ruled out. Diagnostic imaging should be the first intervention to address any immediate risks.

A. A decrease in intracellular fluid volume B. An increase in hydrostatic pressure C. An increase in serum sodium D. An increase in vascular fluid volume

Correct Answer is D

Explanation

A. A decrease in intracellular fluid volume: A reduction in intracellular fluid volume often results from hypertonic conditions in the extracellular space, which can draw water out of cells. This shift can actually increase serum osmolality rather than decrease it.
B. An increase in hydrostatic pressure: Increased hydrostatic pressure promotes fluid movement from the vascular space into the interstitial tissues, contributing to edema. However, this does not significantly impact the concentration of solutes in the serum and therefore does not directly cause a decrease in osmolality.
C. An increase in serum sodium: Sodium is the main contributor to serum osmolality, so an increase in serum sodium raises osmolality. This is the opposite of what occurs in heart failure, where sodium levels are often diluted due to fluid retention.
D. An increase in vascular fluid volume: In heart failure, the kidneys retain fluid in response to decreased cardiac output, expanding the vascular volume. This excess water dilutes the concentration of solutes in the blood, such as sodium, leading to a decrease in serum osmolality.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

A nurse is caring for a client who has heart failure (HF). Which of the following should the nurse identify as a cause for the client's decreased serum osmolality?

Correct Answer is D

Explanation

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