A nurse is assisting a sexual assault nurse examiner (SANE) with the care of a client who has experienced sexual assault. The nurse should identify which of the following as the role of the SANE?

Request the police to gather evidence of the incident.

Provide legal testimony on behalf of the client.

Protect the client from further harm.

Require the client to call the police.

Answer and Explanation

The Correct Answer is C

A. Request the police to gather evidence of the incident. The SANE is responsible for collecting forensic evidence, not the police. While law enforcement may be involved, the SANE conducts the medical forensic examination and ensures evidence is properly documented and preserved.
B. Provide legal testimony on behalf of the client. The SANE can provide expert testimony regarding the forensic examination and findings but does not act as a legal representative for the client. Their role is primarily medical and forensic rather than legal advocacy.
C. Protect the client from further harm. A key responsibility of the SANE is ensuring the client’s immediate safety and well-being. This includes offering medical care, emotional support, and referrals to crisis resources while maintaining a trauma-informed approach.
D. Require the client to call the police. The decision to report the assault to law enforcement is the client’s choice. The SANE provides information about reporting options but does not force or require the client to involve the police.

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Correct Answer is B

Explanation

A. Identification phase. In this phase, the nurse and client begin to build a therapeutic relationship and establish trust. The focus is on identifying the client's needs and concerns rather than actively engaging in therapeutic interventions like guided therapy.
B. Exploitation phase. During the exploitation phase, the nurse encourages the client to utilize the resources and therapeutic interventions available to them. This is an appropriate time to suggest guided therapy sessions, as the client is actively engaged in exploring their issues and working toward improvement.
C. Resolution phase. The resolution phase involves evaluating the progress made and preparing for the termination of the nurse-client relationship. It is not the appropriate time to introduce new therapeutic modalities, as the focus shifts to consolidating gains and planning for future support.
D. Orientation phase. The orientation phase establishes the groundwork for the therapeutic relationship, including discussing goals and expectations. While important, it is not the phase where guided therapy sessions would typically be suggested, as the relationship is still in its initial stages.

A. Review treatment goals that have been accomplished. B. Introduce the concept of discharge planning. C. Gather data about the client's home situation. D. Provide personal contact information to the client for use in case of emergency.

Correct Answer is A

Explanation

A. Review treatment goals that have been accomplished. In the termination phase of the nurse-client relationship, it is essential to evaluate and review the progress made towards the treatment goals. This helps reinforce the client's achievements and prepares them for future independence.
B. Introduce the concept of discharge planning. While discharge planning is important, it is typically discussed earlier in the nursing process rather than during the termination phase. By this point, the client should already be aware of their discharge plans.
C. Gather data about the client's home situation. This action is more appropriate during the initial assessment phase or when planning care, rather than during termination. The focus should be on reflecting on progress and preparing for discharge.
D. Provide personal contact information to the client for use in case of emergency. This is not appropriate in the termination phase, as it can blur professional boundaries and may not adhere to nursing ethical standards. Instead, referrals to appropriate resources should be provided.

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A nurse is assisting a sexual assault nurse examiner (SANE) with the care of a client who has experienced sexual assault. The nurse should identify which of the following as the role of the SANE?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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