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 A
Explanation
Caring for diverse clients will require balancing differences and needs acknowledges the importance of recognizing and respecting cultural diversity among clients. Each individual may have unique cultural backgrounds, beliefs, values, and needs. The nurse must balance these differences effectively to provide care that is sensitive to each client's cultural context.
B. It assumes homogeneity among individuals within the same neighborhood, disregarding the reality of cultural diversity even within small geographic areas.
C. It suggests that all clients, regardless of cultural background, should receive the same standard of care.
D. It disregards the importance of considering clients' cultural diversity in developing the plan of care.
Correct Answer is C
Explanation
Nausea refers to the sensation of feeling sick to the stomach, and it is a symptom that is reported by the client. Since it is based on the client's perception and cannot be directly observed by the nurse, it is considered subjective data.
A. Blood pressure is a measurable vital sign that can be obtained using a blood pressure cuff and stethoscope.
B. Cyanosis is a bluish discoloration of the skin or mucous membranes due to insufficient oxygenation of the blood.
D. Petechiae are small, pinpoint-sized red or purple spots on the skin that result from bleeding under the skin.
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