A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?
Ask the client for permission to take photographs.
Provide community sexual assault support contacts.
Document the client's verbatim statements.
Determine any physical signs of injury.
The Correct Answer is C
Answer: c. Document the client's verbatim statements.
Here's why the other options are wrong:
- a. Ask the client for permission to take photographs: While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
- b. Provide community sexual assault support contacts: Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
- d. Determine any physical signs of injury: Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.
Documenting the client's verbatim statements is the most important initial action because:
- It preserves the client's account of the assault in their own words.
- It allows for accurate reporting and investigation.
- It can be used as evidence in legal proceedings.
Here are some supporting points:
- The Rape, Abuse & Incest National Network (RAINN): "Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
- The National Sexual Assault Hotline: "Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]
In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.
Choice B rationale:
Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.
Choice C rationale:
Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.
Choice D rationale:
Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Lithium is a mood stabilizer commonly used to treat bipolar disorder. It helps to regulate mood swings, prevent manic episodes, and reduce the risk of depressive episodes.
Choice B rationale:
Donepezil is not used to treat bipolar disorder. It is an acetylcholinesterase inhibitor primarily used to treat symptoms of Alzheimer's disease.
Choice C rationale:
Valproate (Depakote) is another mood stabilizer used in the treatment of bipolar disorder. It can help manage both manic and depressive episodes, as well as prevent future mood swings.
Choice D rationale:
Carbamazepine (Tegretol) is an anticonvulsant medication that also has mood-stabilizing properties. It is often prescribed for individuals with bipolar disorder, especially those who do not respond well to lithium.
Choice E rationale:
Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. It is not a primary medication choice for bipolar disorder.
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