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 C
Explanation
The correct answer is choice C. Walk with the client at a gradually slower pace.
Choice A rationale:
Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.
Choice B rationale:
Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.
Choice C rationale:
Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.
Choice D rationale:
Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.
Correct Answer is A
Explanation
Choice A rationale:
In a democratic leadership style, the leader involves the group in decision-making and encourages open discussion. By asking the group for their input on resolving the bathroom issue, the nurse is demonstrating democratic leadership.
Choice B rationale:
A surrogate leadership style involves a designated individual acting as a substitute for the leader. It's not applicable in this scenario where the nurse is involving the group in decision-making.
Choice C rationale:
Laissez-faire leadership involves minimal interference and decision-making by the leader. In this scenario, the nurse is actively seeking group input, which contradicts the laissez-faire approach.
Choice D rationale:
An autocratic leadership style involves the leader making decisions without group input. Since the nurse is soliciting ideas from the group, this style doesn't apply here.
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