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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.

Answer and Explanation

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.

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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.

A. Reviewing the client's toxicology laboratory report. B. Initiating suicide precautions. C. Making a contract with the client for eating behavior. D. Administering the Hamilton Depression Scale.

Correct Answer is B

Explanation

Choice A rationale:

Reviewing the client's toxicology laboratory report is not the priority action in this situation. While assessing toxicology can provide valuable information, the immediate concern is the client's safety due to their admission of thoughts of self-harm with a plan. Toxicology can be relevant but addressing the immediate risk takes precedence.

Choice B rationale:

Initiating suicide precautions is the priority action in this case. The client's admission of thoughts of self-harm with a plan indicates a high risk for suicide. Suicide precautions involve closely monitoring the client, removing any potential means of self-harm, and providing a safe environment. Addressing the client's immediate safety is of utmost importance.

Choice C rationale:

Making a contract with the client for eating behavior is not the priority action in this situation. While eating behavior might be a concern for some individuals with borderline personality disorder, depression, and substance abuse, the client's current statement about self-harm takes precedence. Ensuring the client's safety comes before addressing other aspects of their care.

Choice D rationale:

Administering the Hamilton Depression Scale is not the priority action in this scenario. While assessing the severity of the client's depression is important, the immediate concern is their safety due to the expressed thoughts of self-harm. Once the client's safety is ensured, further assessment and evaluation can take place.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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