A young female client is admitted to the emergency room because she was raped that evening by her date.
How should the registered nurse record the client's chief complaint in the medical record?
Gent clams that she was forced to participate in sexual intercourse by a friend
Client States “my date raped me tonight."
Client has been sexually assaulted last night at 10 pm
Client reported that she had sexual relations against her Will and she feels very bad
The Correct Answer is B
This statement clearly and accurately conveys the client's complaint of being raped by her date.
Option a uses colloquial language and may not accurately convey the severity and trauma of the situation.
Option c uses vague language that does not clearly state the nature of the incident.
Option d uses subjective language that may not be helpful for accurately documenting the client's complaint.
It's important for healthcare providers to use appropriate language when documenting sensitive situations like sexual assault to ensure clear communication among the healthcare team and accurate documentation for legal and forensic purposes.
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Related Questions
Correct Answer is C
Explanation
This response acknowledges the client's concerns and invites further discussion about their experience. The nurse can use this information to assess the severity and duration of the client's symptoms, as well as any potential triggers or stressors that may be contributing to their anxiety and inability to concentrate.
Option a "Have you talked to your friends about this yet?" may not be an appropriate response, as the client may need more professional support than what their friends can provide.
Option b "I have problems too, everybody has problems" may be dismissive of the client's concerns and may not help them feel heard or understood.
Option d "Have you talked to your parents about this yet?" may not be an appropriate response, as the client may not feel comfortable discussing their concerns with their parents or may need more professional support than what their parents can provide.
Option e "Why do you think you are so anxious?" may be seen as confrontational and may not help the client feel heard or understood.
Option f "It sounds like you're having a difficult time" acknowledges the client's concerns but does not invite further discussion or provide an opportunity for the nurse to gather more information.
Correct Answer is A
Explanation
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
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