A 25-year-old female patient arrives at the emergency department after experiencing sexual violence. As a nurse, what is the highest priority intervention you should perform first?
Document all visible injuries and collect forensic evidence.
Provide the patient with privacy and ensure her immediate safety.
Contact law enforcement to report the assault.
Obtain a detailed account of the assault from the patient.
The Correct Answer is B
Choice A reason: Documentation and evidence collection are important but not the first priority. Safety and privacy must be ensured before proceeding.
Choice B reason: Providing privacy and ensuring immediate safety is the highest priority. The client has experienced trauma and needs a secure environment before any further interventions.
Choice C reason: Contacting law enforcement is necessary but should occur after the client’s immediate safety and consent are addressed.
Choice D reason: Obtaining a detailed account may retraumatize the client if done prematurely. It should follow once safety and support are established.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Displaying disapproval toward the perpetrator is non-therapeutic. The nurse’s role is to support the client, not express personal judgment.
Choice B reason: Probing for details can retraumatize the client and may feel invasive. The nurse should allow the client to share at their own pace.
Choice C reason: Inviting family members may compromise the client’s safety and confidentiality, especially if the perpetrator is a family member.
Choice D reason: Being direct and honest fosters trust and helps the client feel safe. Clear communication is therapeutic and supports recovery.
Correct Answer is D
Explanation
Choice A reason: Soup requires utensils and may be difficult for a client with poor concentration and hyperactivity to manage.
Choice B reason: A banana is easy to eat but does not provide adequate protein or sustained nutrition.
Choice C reason: Spaghetti requires utensils and is messy, making it impractical for a client in acute mania.
Choice D reason: A peanut butter sandwich is finger food, easy to eat, and provides protein and calories. It is the most appropriate choice for a client with mania who may struggle with focus and coordination.
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