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 D
Explanation
It indicates that the client acknowledges the importance of having a safety plan and is willing to take proactive measures to ensure their well-being and that of their child. This response suggests a positive engagement with the safety plan provided by the nurse.
A. This response indicates that the client may not perceive their current situation as unsafe or may not be ready to take action to address potential safety concerns.
B. This response suggests that the client may have misconceptions about how the presence of a baby in the home affects safety, especially in the context of intimate partner violence.
C. While expressing gratitude for the information provided is a positive response, it does not necessarily indicate whether the client understands the seriousness of the situation or plans to utilize the resources provided.
Correct Answer is ["B","C"]
Explanation
This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.
B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.
C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.
D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.
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