The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.

Choice A is wrong because women are more at risk for hip fractures than men.

This is partly because women lose bone density faster than men do, especially after menopause.

Choice C is wrong because an increase in estrogen will not weaken the bones. In fact, estrogen helps protect the bones from osteoporosis, which is a leading cause of hip fracture.

Some other risk factors for hip fracture include:

• Excessive alcohol and caffeine consumption
• Lack of physical activity
• Low body weight
• Tall stature
• Vision problems
• Dementia
• Medications that cause bone loss
• Cigarette smoking
• Institutional living, such as an assisted-care facility
• Increased risk for falls, related to conditions such as weakness, disability, or unsteady gait

Normal ranges for bone density vary by age and sex, but generally, a T-score of -1.0 or above is considered normal, while a T-score of -2.5 or below is considered osteoporotic. A T-score between -1.0 and -2.5 is considered osteopenic, which means low bone mass.

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.