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 C
Explanation
A. Late-onset schizophrenia typically presents with symptoms such as hallucinations, delusions, disorganized thinking, and social withdrawal. However, this does not differentiate it from typical schizophrenia.
B. Substance use, including cannabis use, is a known risk factor for the development of schizophrenia, particularly in individuals who are genetically predisposed to the disorder. However, cannabis use as a teenager alone does not necessarily indicate late-onset schizophrenia.
C. Paraphrenia or late onset schizophrenia generally occurs later in life and symptoms persist and intensify as the client ages. Schizophrenia is rarely diagnosed after the age of 40 and is considered late onset if diagnosed after the age of 40.
D. Family history of psychosis or schizophrenia is a significant risk factor for developing schizophrenia, including late-onset schizophrenia. However, having a family member who mirrors the client's behaviors of psychosis is not a specific finding indicative of late-onset schizophrenia.
Correct Answer is A
Explanation
A. Acute toxicity to sedatives, especially at high doses, can lead to various central nervous system effects, including severe hallucinations. Hallucinations can involve distorted perceptions of sensory experiences, such as seeing, hearing, or feeling things that are not present. These hallucinations may be vivid, intense, and disturbing, especially during acute intoxication.
B. Negative symptoms are more commonly associated with chronic psychotic disorders like schizophrenia rather than acute toxic reactions.
C. Prolonged hallucinations are less characteristic of acute toxicity and are more commonly seen in conditions like schizophrenia or certain drug-induced psychotic disorders.
D. Prolonged delusions typically characterize chronic psychotic disorders rather than acute toxic reactions.
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