A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)
Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.
Ensure that the police are present when the examination is performed.
Assess and document any bruises and lacerations.
Have the patient shower or wash the perineal area before the examination.
Record a history of the event, using the patient's own words.
Correct Answer : A,C,E
A. Labeling all torn or bloody clothes and placing each item in a separate brown bag is correct as it helps preserve forensic evidence.
B. Ensuring that the police are present during the examination is incorrect because the patient has the right to refuse police presence, and privacy should be maintained.
C. Assessing and documenting any bruises and lacerations is correct to provide an accurate record for legal and medical purposes.
D. Having the patient shower or wash the perineal area before the examination is incorrect because it can destroy crucial forensic evidence.
E. Recording a history of the event using the patient’s own words is correct as it ensures accurate documentation without interpretation or bias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fidelity refers to being loyal, faithful, and keeping promises, but it is not the primary principle when obtaining informed consent.
B. Nonmaleficence means "do no harm," which is important in healthcare but does not directly relate to the process of informed consent.
C. Beneficence involves promoting good and acting in the best interest of the patient but is secondary to ensuring informed consent is given.
D. Veracity is the ethical principle of truth-telling. It is most important when obtaining informed consent because the patient must fully understand the information about the procedure, including the risks and benefits, before giving consent.
Correct Answer is D
Explanation
A. Evaluating the patient's level of consciousness using the Glasgow Coma Scale is important, but it is secondary to ensuring that the airway is open and that breathing is maintained.
B. Informing the patient that the RN-FNE cannot act on the patient's behalf is unnecessary at this point; the priority is immediate medical intervention.
C. Monitoring vital signs, such as blood pressure and pulse, is crucial but secondary to addressing immediate life-threatening conditions like airway compromise.
D. Assessing the patient's airway is the priority because airway compromise is the most critical issue in emergency care. The RN-FNE must stabilize the patient's airway first before proceeding with other assessments.
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