A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

"The police will want to interview you."

"I will call your spouse."

"We'll have to take photographs of those wounds."

"You are safe now."

Answer and Explanation

The Correct Answer is D

D. This statement prioritizes the client's immediate emotional needs by providing reassurance, validation, and a sense of safety in a traumatic situation. It acknowledges the client's distress and communicates empathy and support, which are essential for building trust and rapport and facilitating the client's emotional healing process.
A. The client may feel overwhelmed by the prospect of speaking to the police at that moment, and it may not be the most therapeutic statement to prioritize.
B. Contacting the client's spouse may provide emotional support and assistance, but it may not be the priority therapeutic statement in this situation.
C. The client may already be feeling vulnerable and exposed, and discussing the need for photographs may exacerbate feelings of distress or discomfort.

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Correct Answer is B

Explanation

B. Olanzapine is an antipsychotic medication commonly used to treat acute manic episodes in bipolar disorder. It can help to stabilize mood, reduce agitation, and calm hyperactivity while waiting for lithium to reach therapeutic levels and take effect.
A. Olanzapine is an antipsychotic medication that can have sedative effects and may help with sleep but this statement does not directly address the reason for its use in this specific situation.
C. Like other medications used to treat bipolar disorder, does not cure the condition. Instead, it helps to manage and stabilize symptoms, including manic episodes, by regulating neurotransmitter activity in the brain.
D. Olanzapine is an antipsychotic medication that has a lower risk of causing extrapyramidal side effects compared to typical antipsychotics but this statement does not accurately explain its use in this scenario.

A. assess the client's airway and breathing. B. assess the client's gag reflex. C. call the physician immediately. D. document this as normal findings and reassess in half an hour.

Correct Answer is A

Explanation

A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.

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A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

Correct Answer is A

Explanation

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