The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?
Assessment of the lower extremities
Assessment of the posterior thorax
Assessment of the abdomen
Assessment of the genitalia and rectum
The Correct Answer is D
Given the traumatic nature of sexual assault and the potential for re-traumatization, the assessment of the genitalia and rectum should be conducted last. This allows the nurse to build rapport with the client, establish trust, and address any immediate concerns or needs before proceeding with a potentially distressing examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Maintaining a nonjudgmental attitude allows the client to feel comfortable discussing their alcohol use without fear of criticism or condemnation. It also helps foster honest communication and promotes engagement in the treatment process.
A. It's important to balance sympathy with professionalism and maintain appropriate boundaries.
C. Expressing disapproval of the client's substance abuse can be counterproductive and may hinder the therapeutic relationship.
D. While it's important for the nurse to maintain professionalism and emotional boundaries, completely avoiding displaying any emotional response may come across as cold or detached.
Correct Answer is C
Explanation
Anxiety is a subjective emotional state characterized by feelings of worry, nervousness, or unease. If the client reports feeling anxious, this would be considered subjective because it is based on their own perception of their emotional state.
A. Alert refers to the client's level of consciousness and awareness of their surroundings.
B. Restlessness refers to a feeling of agitation or inability to stay still.
D. Pacing is an observable behavior where the client is walking back and forth in the room.
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