A nurse in an outpatient mental health clinic is assessing a new client. Which of the following findings should the nurse immediately report to the provider?

Rationale for correct choices:

• Fingernail assessment: Broken fingernails can be a sign of a struggle, as the client may have tried to defend themselves during the assault. Such injuries are commonly seen in cases of sexual assault, where victims may attempt to resist or protect themselves.
• Diagnostic results: The positive urine drug screen for GHB is key as it is often used as a "date rape drug" due to its ability to cause sedation, memory loss, and impaired judgment. Its presence supports the possibility of the client being drugged as part of a sexual assault.

Rationale for incorrect choices:

• Blood pressure: Blood pressure readings are typically not indicative of sexual assault. While anxiety or trauma can affect blood pressure, this measurement alone does not provide information directly related to sexual assault. Her BP is also within normal range.
• Abdominal examination: Mild tenderness in the abdomen could be incidental or related to other causes but is not directly linked to the typical findings in a sexual assault case. Abdominal examination would generally not be the primary assessment for identifying sexual assault unless there was significant trauma or injury to the abdomen.
• Temperature: A normal temperature of 37°C (98.6°F) does not indicate anything specific to sexual assault. While fever may occur in cases of infection, it is not a defining characteristic of sexual assault and doesn't help in confirming the occurrence.

A. "We can ask the physician to prescribe a sedative": Offering a sedative is not an appropriate immediate response. While medication may be helpful in managing symptoms, the nurse should first assess the client’s emotional state and risk for self-harm.
B. "Have you thought about harming yourself?": This response is the most appropriate as it directly addresses the client’s emotional distress and risk for self-harm. It opens up a conversation for the nurse to assess the severity of the client's suicidal ideation and ensure their safety.
C. "Can a family member try to obtain temporary custody of your child?": While this may be a valid question later on, it shifts the focus away from the client’s current emotional distress and potential self-harm. The immediate concern should be assessing the client’s safety, not discussing custody.
D. "If you attend counseling, you will get your child back": This response may provide false hope or pressure the client, as there are no guarantees about regaining custody. The nurse should focus on providing support and addressing immediate safety concerns rather than making promises.