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.
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Related Questions
Correct Answer is D
Explanation
A. The Code of Ethics for Nurses offers broad ethical guidelines, but it does not provide specific clinical practice guidelines.
B. The Code does touch on social justice issues, but it is not primarily focused on critiquing societal oppression or domination.
C. While the Code supports good care, it is more about establishing ethical standards rather than providing direct care guidelines.
D. The Code expresses nursing's commitment to society, outlining the profession's ethical standards and obligations toward patients and society as a whole.
Correct Answer is A
Explanation
A. Deep breathing and holding can help relax the patient, reduce pain perception, and enhance the effects of opioid medications.
B. Ambulating may be appropriate but should be done carefully, as it could exacerbate pain or cause dizziness after opioid administration.
C. While distraction like watching TV can help manage pain, it is not as effective as active pain-relieving interventions like deep breathing.
D. Applying ice to the incision site can be helpful for pain management, but deep breathing is more directly beneficial for managing postoperative pain.
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