Exhibits
A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.
Inform the dient that they cannot refuse medical examination
Report laboratory findings to law enforcement.
Prepare to administer prophylaxis for STIs.
Assess for thoughts of self-harm
Recommend emergency contraception to the client.
Correct Answer : C,D,E
A. Inform the client that they cannot refuse medical examination: All patients, including those who have been sexually assaulted, have the legal right to refuse any part of the examination. Informed consent is essential.
B. Report laboratory findings to law enforcement: Unless there is a mandatory reporting law in effect for that specific jurisdiction, results and disclosures require the client's consent before being shared with law enforcement.
C. Prepare to administer prophylaxis for STIs: Clients who have experienced sexual assault are at risk for sexually transmitted infections. Early administration of prophylactic antibiotics is a standard, time-sensitive intervention.
D. Assess for thoughts of self-harm: Sexual assault survivors are at increased risk for depression, suicidal ideation, and PTSD. A mental health assessment should be conducted immediately to ensure safety.
E. Recommend emergency contraception to the client: If pregnancy is a potential concern, emergency contraception should be offered within a limited time window after the assault, regardless of the client’s current hCG level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wart-like texture: A wart-like texture is more typical of squamous cell carcinoma or benign lesions like seborrheic keratosis. Melanomas usually do not have a rough, wart-like surface.
B. Firm and rubbery: Firm, rubbery nodules are more consistent with benign skin growths such as dermatofibromas. Melanomas tend to have irregular texture and color rather than a uniform firmness.
C. A central crater with rolled borders: This description fits basal cell carcinoma, which often presents with a pearly nodule and central ulceration. Melanomas do not commonly have this crater-like appearance.
D. Asymmetric with variegated ring: Melanomas are typically asymmetric with uneven, irregular borders and multiple colors. This variegation and asymmetry are classic warning signs distinguishing melanoma from other lesions.
Correct Answer is A,C,B,D
Explanation
A. Rolls from back to side typically occurs around 4 months of age, as the infant gains initial control of trunk and limbs. This is one of the earliest gross motor milestones.
B. Sits steadily unsupported generally develops by about 8 months, showing further improvement in core strength and postural control.
C. Rolls from back to abdomen follows around 5–6 months, demonstrating increased muscle coordination and control over the trunk and neck.
D. Changes from prone to sitting usually occurs between 9 to 10 months and indicates advanced coordination, enabling independent movement and transition between positions.
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