A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?
“It wouldn’t have mattered what you had worn.”.
“The current styles are an invitation to disaster.”.
“Never mind about blame.
That will be determined by the court.”.
The Correct Answer is A
“It wouldn’t have mattered what you had worn.” This response by a nurse is appropriate because it validates the client’s feelings and helps to reduce self-blame. It also conveys that rape is not caused by the victim’s clothing or behavior, but by the perpetrator’s violence and lack of respect.
Choice B. “The current styles are an invitation to disaster.” is wrong because it implies that the client is responsible for the rape and that she could have prevented it by dressing differently. This response is judgmental and insensitive, and may increase the client’s guilt and shame.
Choice C. “Never mind about blame.
That will be determined by the court.” is wrong because it dismisses the client’s feelings and does not address her emotional needs.
It also suggests that the nurse does not believe the client or support her. This response may make the client feel isolated and distrustful.
Choice D. “Some people don’t have very good self-control.
We have to help them all we can.” is wrong because it excuses the perpetrator’s behavior and shifts the blame to the victim.
It also implies that rape is a result of sexual desire, rather than an act of violence and domination. This response may make the client feel powerless and helpless.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
These interventions help the client to cope with stress by enhancing their social support and teaching them skills to manage stressors.
Choice B is wrong because sedative hypnotics may cause dependence and do not address the underlying causes of stress.
Choice D is wrong because discussing factors that contribute to stress may increase the client’s anxiety and does not provide any solutions.
The normal range for coping is to use adaptive strategies that reduce stress and promote well-being.
Correct Answer is D
Explanation
Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.
Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.
Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.
A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.
Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.
Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.
A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.
Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.
Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.
A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.
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