A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Discuss self-defense techniques with the client.

Give the client a bed bath prior to physical examination.

Inform the client photographs of injuries are required for a police report.

Ask the client to describe the situation.

Answer and Explanation

The Correct Answer is D

A. Discuss self-defense techniques with the client: Incorrect

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

B. Give the client a bed bath prior to physical examination: Incorrect

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

C. Inform the client photographs of injuries are required for a police report: Correct

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

D. Ask the client to describe the situation: Correct

It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.

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Correct Answer is C

Explanation

A. "There really isn't much you can do about that until you are discharged." - This response dismisses the client's feelings and does not offer any support.

B. "You should call your boss and ask if you can have your job back." - This response is directive and may not address the client's emotional needs.

C. "You must feel very concerned and disappointed by that information."

This response shows empathy and acknowledges the client's feelings without making judgments or offering solutions. It validates the client's emotions and opens up a supportive space for further discussion.

D. "I don't understand why your partner would upset you with news like that." - This response may be perceived as judgmental and does not show empathy or understanding.

A. "Are you thinking of harming yourself?" B. "Do you really think your family would be better off without you?" C. "When did you first start feeling this way?" D. "Tell me what is happening right now."

Correct Answer is A

Explanation

A. "Are you thinking of harming yourself?": Correct

This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.

B. "Do you really think your family would be better off without you?": Incorrect

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

C. "When did you first start feeling this way?": Incorrect

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

D. "Tell me what is happening right now.": Incorrect

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

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A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Nursing Test Bank

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