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 D
Explanation
D. Hallucinations, particularly visual hallucinations, are a common manifestation of alcohol withdrawal, typically occurring within 12 to 24 hours after the last drink. These hallucinations can be vivid and may involve seeing objects, people, or animals that are not actually present.
A. Hypertension (high blood pressure) is more commonly associated with alcohol withdrawal, especially during the acute phase.
B. Respiratory depression, characterized by slowed or shallow breathing, is not a typical feature of alcohol withdrawal.
C. Muscle aches are not typically associated with alcohol withdrawal. Instead, symptoms such as tremors, agitation, and insomnia are more common during alcohol withdrawal.
Correct Answer is C
Explanation
C. Codependency refers to a dysfunctional pattern of behavior in which a person excessively relies on another individual (often a partner or family member) for their sense of identity, self- worth, or emotional well-being. In this scenario, the partner's demand to see the client's records
and treatment plan, as well as the assertion of needing to oversee the treatment, suggests an excessive need for control and involvement in the client's life and healthcare decisions.
A. Manipulation involves influencing or controlling someone in a deceptive or dishonest way to achieve one's own goals.
B. Marginalization refers to the exclusion or relegation of a person or group to a lower or outer edge of society or a group.
D. Enabling refers to behaviors that unintentionally or intentionally allow someone to continue engaging in harmful behaviors or avoid facing consequences.
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