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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Resume antithyroid drug therapy.
Antithyroid medications are typically not resumed immediately post-thyroidectomy unless specifically directed by the healthcare provider. The focus post-surgery is often on managing potential complications and ensuring proper healing.

B. Anticipate and monitor for hypothermia.
Hypothermia is not a common concern following thyroidectomy. The nurse should monitor for other more relevant complications such as bleeding, airway obstruction, and hypocalcemia.

C. Prepare to administer radioactive iodine treatments.
Radioactive iodine treatment is usually not administered immediately post-thyroidectomy. It may be considered later, depending on the reason for the thyroidectomy and the individual treatment plan.

D. Maintain a semi-Fowler position.
This is the correct intervention. Maintaining the client in a semi-Fowler position helps reduce strain on the surgical site, facilitates breathing, and minimizes the risk of complications such as bleeding and edema in the neck area. It is an essential part of postoperative care for
thyroidectomy patients.

A. Neurological status B. Circulation C. Current medications D. Allergies E. Exposure F. Ventilation

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

Explanation

A. Neurological status: Assessing the neurological status is crucial in the primary survey to

determine the client's level of consciousness, pupil reactions, and response to stimuli. This helps in identifying any potential brain injury or neurological deficits resulting from the fall.

B. Circulation: Evaluating circulation involves assessing the client's heart rate, blood pressure, and peripheral perfusion. In this scenario, the client's heart rate and blood pressure are provided in the nurse's notes, indicating the need to assess circulation as part of the primary survey.

C. Current medications: While important for the overall assessment and care of the client, assessing current medications is typically part of the secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions.

D. Allergies: While allergies are essential information for the client's overall care, they are typically addressed during the secondary survey or during the history-taking process rather than as part of the primary survey.

E. Exposure: Assessing exposure involves ensuring the client is adequately covered and protected from environmental factors, especially in trauma situations where there may be significant blood loss or risk of hypothermia. This includes removing clothing to assess for additional injuries or bleeding.

F. Ventilation: While ventilation is crucial for assessing the client's respiratory status, including respiratory rate and effort, it is typically part of the primary survey rather than the primary survey itself. Assessing ventilation helps determine if the client is adequately breathing and oxygenating.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?

Correct Answer is D

Explanation

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

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

Explanation

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