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. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.

A. "My boyfriend is too passionate for me." B. "I know it was not my fault." C. "I'll just go on double dates from now on." D. "Next time I won't wear such a sexy dress."

Correct Answer is B

Explanation

B. This statement demonstrates progress and indicates that the client is beginning to take responsibility off themselves for the sexual assault. Acknowledging that the assault was not their fault is a crucial step in healing from trauma. It shows an acceptance of reality and a shift away from self-blame or feelings of guilt.
A. It may indicate that the client is still struggling to acknowledge the true nature of the assault and may not have fully processed their feelings and experiences related to the trauma.
C. This statement may suggest avoidance or attempts to control future situations to prevent similar experiences. While seeking support and safety measures can be beneficial, solely relying on external factors such as double dates to prevent sexual assault may not address underlying issues or promote healing from the trauma.
D. It suggests a continuation of internalized victim-blaming beliefs and may indicate that the client has not fully shifted away from feelings of guilt or responsibility for the assault.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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