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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cover client with cooling blanket.
This could help manage the fever but is not the highest priority in the context of acute adrenal crisis.
B. Obtain an analgesic prescription.
Pain management is important, but it is not the immediate priority in a life-threatening adrenal crisis.
C. Infuse an intravenous fluid bolus.
This is the correct answer because the client is experiencing hypotension (low blood pressure), which is critical in an acute adrenal crisis. IV fluids are essential to restore blood pressure and perfusion.
D. Administer PRN oral antipyretic.
Managing the fever is important, but not the first priority. The client’s hemodynamic instability needs to be addressed immediately.
Correct Answer is B
Explanation
A. Gained 10 lb (4.5 kg) within one month. Weight gain is not typically associated with the onset of type 1 diabetes. In fact, weight loss is more common due to the body's inability to use glucose properly.
B. Drinks more fluids than previously. Increased thirst (polydipsia) is a classic symptom of type 1 diabetes due to high blood sugar levels causing dehydration.
C. Voids only one or two times per day. Increased urination (polyuria) is a common symptom of type 1 diabetes as the body attempts to excrete excess glucose, so decreased urination is unlikely.
D. Refuses to eat favorite meals at home. While changes in appetite can occur, it is not a primary symptom of type 1 diabetes. Increased hunger (polyphagia) is more typical.
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