The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

"We need to offer the client emotional support especially when obtaining specimens."

"Did you see that outfit that the client is wearing? What did they expect?"

The client feels like they won't be believed since there was alcohol involved during the date."

"When the client said "stop." that was enough for the perpetrator to get up and walk away."

Answer and Explanation

The Correct Answer is B

Explanation: This statement is highly inappropriate and victim-blaming. It implies that the client's clothing choices are somehow responsible for the sexual assault they experienced. Victim-blaming is never acceptable and can be harmful to the survivor, making them feel ashamed and responsible for the actions of the perpetrator. As healthcare professionals, nurses should always respond to victims of sexual assault with empathy, compassion, and without judgment.

The other statements (A, C, and D) are all appropriate and acknowledge the seriousness of the situation:

A. "We need to offer the client emotional support especially when obtaining specimens." Explanation: This statement recognizes the need for emotional support during the examination process, which can be distressing for the survivor. Providing emotional support and ensuring the client's comfort and consent during the examination are crucial aspects of caring for a sexual assault survivor.

C. "The client feels like they won't be believed since there was alcohol involved during the date." Explanation: This statement highlights the survivor's feelings and concerns about being believed due to alcohol involvement. It emphasizes the importance of creating a safe and non-judgmental environment for the client, where they can share their experience and receive appropriate care and support.

D. "When the client said 'stop,' that was enough for the perpetrator to get up and walk away." Explanation: This statement indicates an understanding of the importance of consent and acknowledges that the client's clear expression of refusal should have been respected. Understanding and respecting consent is crucial when discussing cases of sexual assault.

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Correct Answer is ["A","D","E"]

Explanation

The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:

A. Prior to performing any intervention that requires touch, the nurse will ask permission.

This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.

D. The nurse will perform a continuous assessment of the client's anxiety level.

Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.

E. Have security present outside of the client's room to prevent anyone from coming in.

Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.

It is not appropriate to:

B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.

C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.

A. Anticipatory grief B. Disenfranchised grief C. Complicated grief D. Absence of grief

Correct Answer is A

Explanation

Anticipatory grief refers to the emotional response and mourning that occurs before an actual loss or death. In this case, the client is grieving the loss of the pregnancy due to the decision to have an elective abortion. The grief arises from the anticipation of not being able to have the child at this time, even though they may want to have children in the future.

B- Disenfranchised grief: Disenfranchised grief refers to a type of grief that is not openly acknowledged or socially validated. It occurs when a person experiences a loss that is not commonly recognized or is not socially accepted. In this case, the client's grief is not disenfranchised because the loss of an unintended pregnancy through elective abortion is openly acknowledged and socially accepted.

C- Complicated grief: Complicated grief, also known as prolonged grief or unresolved grief, occurs when a person experiences intense, prolonged, or incapacitating grief that doesn't seem to improve over time. It can be a result of traumatic loss or when the person has difficulty accepting the reality of the loss. The client's grief over the elective abortion does not necessarily indicate complicated grief since it is a normal response to the loss of the pregnancy.

D- Absence of grief: Absence of grief would mean that the client is not experiencing any emotional response or sorrow after the elective abortion, which is unlikely in this situation. The client is crying and expressing emotions, indicating the presence of grief.

In summary, the most appropriate choice for the client's experience is "Anticipatory grief" since the client is grieving the loss of the pregnancy before it actually occurred due to the timing of the pregnancy not aligning with their plans.

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The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A client has just had an elective abortion to end an unintended pregnancy. Afterward, the client cries because although they wanted to have children in future years, this pregnancy was not well timed. Which type of grief is this client most likely to experience?

Correct Answer is A

Explanation

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