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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Administering epinephrine is the immediate priority when managing anaphylaxis. Epinephrine is the first-line treatment for anaphylaxis as it helps to rapidly reverse severe allergic symptoms, such as airway constriction, swelling, and hypotension.

A. While assessing the client's neurologic status is important for monitoring their overall condition, it may not be the immediate priority when the client is experiencing symptoms of an allergic reaction, particularly anaphylaxis.

B. While consulting an allergy specialist may be necessary for further evaluation and management of the client's allergic condition, it is not the immediate priority.

D. While determining the cause of the hives is important for identifying the allergen and preventing future allergic reactions, it is not the immediate priority during an acute episode of anaphylaxis.

A. The client explains they are not planning to leave their home. B. The client thinks their home will be safer now that there is a baby in the house C. The client thanks the nurse for the information. D. The client puts the number of the crisis center into their phone.

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.

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The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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