A sexual assault nurse examiner (SANE) is a caring for a client who experienced sexual assault. Which of the following actions should the nurse take?
Request the police to gather evidence of the incident.
Require the client to call the police.
Provide legal testimony on behalf of the client.
Protect the client from further harm.
The Correct Answer is D
D. In the immediate aftermath of a sexual assault, the primary focus of the SANE nurse is to ensure the safety and well-being of the client. This includes providing a safe and supportive environment for the client, assessing and treating any physical injuries, addressing immediate medical needs, and offering emotional support and crisis intervention.
A, B, and C involve aspects of legal procedures and involvement of law enforcement, but they may not be appropriate or feasible for every client in every situation. Additionally, the decision to involve law enforcement or pursue legal action should be made in collaboration with the client and should prioritize their safety, autonomy, and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Individuals with borderline personality disorder (BPD) often experience intense and unstable emotions, impulsivity, and difficulties in regulating their emotions and behaviors. As a result, transitions, such as being discharged from the hospital, can be particularly challenging and may increase the risk of self-harm or suicidal behavior.
B. While dialectical behavior therapy (DBT) is an evidence-based treatment for BPD and focuses on teaching coping skills to manage emotions and reduce self-harming behaviors, attending therapy sessions may actually decrease the risk of self-harm for individuals actively participating in treatment.
C. Narrative therapy is another therapeutic approach that focuses on helping individuals reframe their life stories and experiences. While narrative therapy may be beneficial for some aspects of BPD treatment, it may not specifically address the immediate risk factors for self-harm.
D. Getting married may be a significant life event that brings about both positive and negative emotions, but it does not inherently indicate the highest risk for self-harm in individuals with BPD.
Correct Answer is A
Explanation
A. This response provides accurate information about the early warning signs of schizophrenia spectrum disorders. Social withdrawal and isolation are commonly observed before the onset of
psychotic symptoms, such as hearing voices. By acknowledging this pattern, the nurse validates the client's experience and offers insight into potential warning signs.
B. This fails to address the client's concern or provide meaningful information about the potential significance of their behavior.
C. While exploring the client's personality traits and how they relate to socialization is valid, this response does not directly address the client's concern about isolating themselves before experiencing symptoms of schizophrenia.
D. This response makes an assumption about the client's motivations for avoiding their friend and implies a connection between social isolation and hearing voices that may not be accurate.
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