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: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.
Correct Answer is B
Explanation
Choice A reason: Fibromyalgia, a chronic pain condition, is not a contraindication for oral contraceptives. Estrogen and progesterone do not exacerbate fibromyalgia’s musculoskeletal or neurological symptoms, as they primarily affect hormonal pathways, making contraceptives safe for use in clients with this condition.
Choice B reason: Hypertension is a contraindication for oral contraceptives, as estrogen increases renin-angiotensin activity, elevating blood pressure. This risks cardiovascular events like stroke or myocardial infarction, especially in clients with existing hypertension, necessitating alternative contraception to avoid vascular complications.
Choice C reason: Iron-deficiency anemia is not a contraindication, as oral contraceptives may reduce menstrual bleeding, improving anemia by decreasing iron loss. Their hormonal effects do not impact erythropoiesis, making them potentially beneficial for anemic clients, unlike hypertension, which poses risks.
Choice D reason: Human papillomavirus (HPV) is not a contraindication, as it affects cervical epithelium, not hormonal pathways. While some studies suggest a weak link to cervical cancer, HPV vaccination and screening mitigate risks, making oral contraceptives safe for clients with HPV.
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