A young woman arrives to the Emergency Department and reports that she was raped and stabbed.
What should the nurse do first?
Call the Sexual Nurse Examiner.
Assess vital signs.
Call her parents to ask for permission to treat.
Contact Security in case the perpetrator arrives.
The Correct Answer is B
The nurse should prioritize the physical safety and stability of the patient who has been raped and stabbed.
Assessing vital signs is the first step in determining the patient’s condition and identifying any life-threatening injuries that need immediate intervention.
Choice A is wrong because calling the Sexual Nurse Examiner is not the first action to take.
The Sexual Nurse Examiner is a specially trained nurse who can perform a forensic examination and collect evidence from the patient, but this should be done after ensuring the patient’s physical safety and obtaining consent.
Choice C is wrong because calling her parents to ask for permission to treat her is not necessary or appropriate.
The patient is an adult who can consent to her own treatment unless she is incapacitated or mentally incompetent.
Calling her parents without her permission may violate her privacy and autonomy.
Choice D is wrong because contacting Security in case the perpetrator arrives is not the most urgent action to take.
The nurse should focus on the patient’s needs and not assume that the perpetrator will follow her to the hospital.
Security measures can be taken later if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.
The client may or may not need to use the bedpan depending on their fluid intake and output.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.
The client may or may not need to vomit depending on their underlying condition.
Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.
Correct Answer is B
Explanation
Gently pull the auricle up and back before instilling the drops. This technique straightens the auditory canal and allows the drops to reach the eardrum.
It also prevents contamination of the ear canal by the finger.
Choice A is wrong because pulling the auditory canal down and toward the front is the proper method for children, not adults.
This technique is used for children because their auditory canal is shorter and more curved than adults.
Choice C is wrong because lowering the head and taking a deep breath during the instillation has no effect on the administration of otic drops.
It may also cause discomfort or dizziness for the client.
Choice D is wrong because wearing sterile gloves and inserting one finger in the canal is unnecessary and potentially harmful.
It may introduce bacteria or damage the ear canal or eardrum.
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