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
C. This statement indicates an understanding of the needs of clients who are part of vulnerable populations because it demonstrates an awareness of the importance of client-centered care. Addressing the problem that the client believes is the most significant acknowledges the client's autonomy, respects their perspective, and ensures that their needs are prioritized.
A. This statement suggests a narrow focus on the immediate reason for the client's visit. While addressing the client's presenting concern is important, a limited assessment may overlook underlying issues or social determinants of health that could impact the client's well-being.
B. While privacy is important, asking clients for income or financial information may be necessary to assess their eligibility for financial assistance programs or to understand socioeconomic factors that may impact their health and access to care.
D. This statement suggests overlooking the importance of cultural competence in nursing practice. Cultural traditions, beliefs, and practices can significantly influence a client's health beliefs, behaviors, and preferences for care.
Correct Answer is C
Explanation
C. Dementia related to a traumatic brain injury can result in a variety of cognitive and physical impairments. A shuffling gait, characterized by short steps with feet barely leaving the ground, is often associated with Parkinsonian symptoms, which can occur in advanced stages of dementia or as the condition progresses. Therefore, a shuffling gait would indicate worsening of the client's condition.
A. While visual disturbance can occur in individuals with dementia, visual field cuts alone may not necessarily indicate worsening of the condition unless they are accompanied by other concerning symptoms.
B. CD4 counts are a measure of immune system function, particularly in relation to HIV/AIDS. Decreased CD4 counts are not typically associated with dementia related to traumatic brain injury and would not be a relevant finding in this context.
D. Chorea is not a common feature of dementia related to traumatic brain injury. The presence of chorea may indicate a different underlying neurological condition or complication
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