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","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.
Correct Answer is C
Explanation
Assessing the client's ability to function is crucial for understanding the impact of grief and depression on their daily life and functioning. Evaluating functional status helps determine the severity of the client's condition and guides interventions to promote recovery and improve quality of life.
A. Spiritual assessment is valuable for understanding the client's beliefs, values, and sources of strength, but it may not directly address the client's current symptoms of grief, depression, and associated sleep disturbances, weight loss, anger, and irritability.
B. While assessing cultural factors is important for providing culturally sensitive care, it may not be the immediate priority compared to addressing the client's symptoms and functional status.
D. Social support plays a significant role in coping with grief and depression. However, while social support is important, the immediate priority may be to address the client's symptoms and functional status.
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