A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?
Instruct the client to shower and change their clothes.
Ask the client for details about the assault.
Reassure the client that their injuries are not life-threatening.
Limit the number of staff members providing care for the client.
The Correct Answer is D
Choice A reason: Instructing the client to shower and change clothes is inappropriate, as it may destroy forensic evidence critical for legal proceedings. Evidence preservation is a priority post-sexual assault, and showers are delayed until after forensic examination, making this intervention incorrect and potentially harmful.
Choice B reason: Asking for details about the assault can retraumatize the client and is not the nurse’s role immediately post-assault. Trained forensic examiners or counselors handle such discussions sensitively. This action risks emotional harm and is inappropriate for initial care, making it incorrect.
Choice C reason: Reassuring the client that injuries are not life-threatening may minimize their trauma and emotional distress. The focus should be on emotional support and safety, not downplaying injuries, which may be perceived insensitively. This intervention is inappropriate for trauma-informed care, making it incorrect.
Choice D reason: Limiting staff members providing care reduces the client’s exposure to multiple providers, minimizing retraumatization and ensuring consistency. This trauma-informed approach fosters trust and safety post-sexual assault, aligning with best practices for psychological support, making it the correct intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A WBC count of 1,300/mm³ indicates severe leukopenia, a contraindication for clozapine due to its risk of agranulocytosis. Low white cells increase infection risk, requiring immediate discontinuation or monitoring per FDA guidelines, making this the critical finding to identify.
Choice B reason: Hemoglobin of 16 g/dL is within normal range (14-18 g/dL) and does not contraindicate clozapine use. Normal hemoglobin supports adequate oxygen transport, so this finding is unremarkable and incorrect for identifying a contraindication.
Choice C reason: Fasting blood glucose of 124 mg/dL indicates mild elevation but is not a contraindication for clozapine, which may worsen glucose control. Monitoring is needed, but this level does not preclude use, making it incorrect.
Choice D reason: Platelet count of 200,000/mm³ is normal (150,000-450,000/mm³) and does not contraindicate clozapine. Normal platelets ensure proper clotting, so this finding is not a concern for clozapine administration, making it incorrect.
Correct Answer is D
Explanation
Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.
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