Which of the following actions should the nurse take first when performing an assessment on a client who reports being sexually assaulted?

Document the client's verbatim statements.

Ask the client for permission to take photographs.

Determine any physical signs of injury.

Provide community sexual assault support contacts.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Documenting the client's verbatim statements is crucial for legal purposes and for ensuring that the client's experience is accurately recorded. However, this is not the first action to take. The nurse must first address any immediate medical concerns, which include identifying and treating injuries.

Choice B reason:

Asking for permission to take photographs is an important part of collecting evidence, but it should be done after addressing immediate health concerns and with the client's consent. It is also essential that this step is performed in a sensitive and non-judgmental manner.

Choice C reason:

Determining any physical signs of injury is the most critical initial step. The nurse must assess for injuries that may require immediate intervention. This aligns with the priorities of care in emergency nursing, which focus on stabilizing the patient's condition and addressing urgent health issues.

Choice D reason:

Providing community sexual assault support contacts is an important aspect of holistic care and ensures that the client has access to ongoing support. However, this action follows after immediate health concerns have been addressed and should be part of the long-term care plan.

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Correct Answer is C

Explanation

Choice A reason: Verbalizing disapproval of the client’s substance abuse is not therapeutic and can harm the nurse-client relationship. It may cause the client to feel judged and less likely to be open about their struggles, hindering the treatment process.

Choice B reason: While it is important to maintain professionalism, avoiding any emotional response can make the nurse seem distant and uncaring. A balance between empathy and professional detachment is necessary to build rapport and trust with the client.

Choice C reason: Maintaining a nonjudgmental attitude is essential in the therapeutic setting, especially during the initial interview at an alcohol treatment center. It helps to create a safe environment where the client feels respected and understood, which can facilitate openness and honesty about their issues with substance abuse.

Choice D reason: Offering sympathetic support is a positive approach, but it must be carefully balanced with professional boundaries. Sympathy can sometimes be mistaken for pity, which might not be empowering for the client. Empathy, which involves understanding and sharing the feelings of another, is generally more appropriate in a therapeutic setting.

A. Ritualistic behavior B. Short attention span C. Spinning a toy repetitively D. Consistent limit testing E. Delayed language development

Correct Answer is ["A"]

Explanation

Choice A Reason:

Ritualistic behavior is a common characteristic of autism spectrum disorder (ASD). Children with ASD may engage in routines or rituals and may become distressed if these routines are disrupted. This behavior provides a sense of order and predictability for them.

Choice B Reason:

A short attention span is often observed in children with ASD. They may have difficulty focusing on tasks or activities that do not interest them, which can affect their learning and social interactions.

Choice C Reason:

Repetitive behaviors, such as spinning a toy, are hallmark signs of ASD. These behaviors are often referred to as "stimming" and can serve various functions, including self-regulation and sensory processing.

Choice D Reason:

Consistent limit testing is not typically associated with ASD. While children with ASD may have difficulty understanding social norms and boundaries, limit testing implies a behavioral response that is not characteristic of the core symptoms of ASD.

Choice E Reason:

Delayed language development is a common finding in children with ASD. They may have limited speech or not speak at all, and those who do talk often have difficulty with the use of language in a social context.

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Which of the following actions should the nurse take first when performing an assessment on a client who reports being sexually assaulted?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following approaches should the nurse take when interviewing a client during admission to an alcohol treatment center?

Correct Answer is C

Explanation

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A"]

Explanation

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