The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?
Listen attentively to the client's description of the event.
Report the incident to the university's security department.
Do not allow client to shower until all evidence is obtained.
Determine the client's personal reaction to the reported rape.
The Correct Answer is C
A. Listen attentively to the client's description of the event. While important for providing emotional support, it is secondary to preserving forensic evidence.
B. Report the incident to the university's security department. This is necessary but not as immediately critical as preserving evidence.
C. Do not allow client to shower until all evidence is obtained. Preserving evidence is the highest priority in this situation to ensure a thorough forensic investigation and legal process.
D. Determine the client's personal reaction to the reported rape. Understanding the client's emotional state is important for providing support, but it should be done after ensuring that critical forensic evidence is collected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client is stable with no drainage from the Jackson-Pratt drain, indicating that there is no immediate issue that needs to be addressed. The bulb is compressed, suggesting proper function. Therefore, this client can be safely assessed last.
B. An adult client with a rectal tube draining clear, pale red liquid drainage. The presence of pale red drainage can indicate a potential issue that needs monitoring, such as bleeding or other complications, thus requiring a more timely assessment.
C. An older client with a distended abdomen and no drainage from the nasogastric tube. A distended abdomen and lack of drainage could indicate a blockage or other serious issue that needs immediate attention.
D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. Dark red drainage can indicate active bleeding, which is a critical issue that needs to be addressed promptly to prevent complications.
Correct Answer is A
Explanation
A. Redress the abdominal incision The client's abdominal dressing is no longer occlusive, which exposes the surgical wound to potential contamination and infection. The nurse must immediately cleanse and redress the incision to protect it. While the client may try to pick at it again, maintaining wound integrity is the priority clinical intervention.
B. Leave the lights on in the room at night Leaving bright lights on at night can disrupt the client's circadian rhythm, worsen sleep deprivation, and increase confusion or sundowning behaviors. A dim nightlight is a better alternative to provide orientation without causing sensory overload or sleep disruption.
C. Apply soft bilateral wrist restraints Restraints are a restrictive measure that should only be used as a last resort after all non-pharmacological and behavioral interventions have failed. In clients with dementia, physical restraints often escalate agitation, increase confusion, and pose significant safety risks such as skin breakdown or entanglement.
D. Replace the IV site with a smaller gauge The IV insertion site is described as pink, which indicates early signs of irritation or phlebitis. Changing the gauge of the catheter at the current site does not resolve the inflammation or protect the line from being pulled. The IV needs to be monitored, protected, or discontinued/relocated if phlebitis progresses, but changing the gauge is not the solution.
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