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 ["A","B","C","D"]

Explanation

A. Withdrawn: The child's withdrawn behavior, such as looking downcast and avoiding eye contact, may indicate emotional distress or a potential psychological issue, which can be associated with factitious disorder. Individuals with factitious disorder may exhibit emotional signs that reflect their internal struggles and manipulation of health-related situations.
B. Multiple hospitalizations: Frequent hospitalizations, especially without a clear medical diagnosis, can suggest factitious disorder. This pattern often reflects a behavior where an individual seeks medical attention and care, indicating a need to assume the sick role.
C. Unexplained abdominal pain: The presence of unexplained abdominal pain, particularly when combined with a history of seeking medical attention, aligns with factitious disorder. In this condition, individuals often feign or produce symptoms for psychological reasons, leading to repeated medical evaluations without a clear medical basis.
D. Excessive thinking about health: An intense preoccupation with health issues can be indicative of factitious disorder. This behavior demonstrates a focus on illness that may lead to manipulative behaviors in seeking attention or care.
E. Recent trauma: While trauma can contribute to various psychological conditions, it is not specifically indicative of factitious disorder. Many individuals may experience trauma without developing this disorder, making it less relevant in this context.

A. The importance of avoiding foods that contain tyramine when taking an antipsychotic B. The importance of routine red blood cell count laboratory work when taking an antipsychotic C. The importance of limiting fluid intake when taking an antipsychotic D. The importance of medication adherence after the resolution of acute psychosis when taking an antipsychotic

Correct Answer is D

Explanation

A. The importance of avoiding foods that contain tyramine when taking an antipsychotic. Tyramine restrictions apply to monoamine oxidase inhibitors (MAOIs), not antipsychotics like clozapine. MAOIs require dietary modifications to prevent hypertensive crises, but clozapine does not interact with tyramine-containing foods.
B. The importance of routine red blood cell count laboratory work when taking an antipsychotic. Clozapine requires regular white blood cell (WBC) and absolute neutrophil count (ANC) monitoring, not red blood cell counts, due to the risk of agranulocytosis, a potentially fatal condition that can lead to severe infections.
C. The importance of limiting fluid intake when taking an antipsychotic. Fluid restriction is not a standard recommendation for clozapine use. However, some antipsychotics can cause polydipsia (excessive thirst), which may lead to water intoxication, but fluid restriction is not a routine precaution.
D. The importance of medication adherence after the resolution of acute psychosis when taking an antipsychotic. Antipsychotic medications, including clozapine, require long-term adherence to prevent symptom relapse. Clients may feel better and stop taking their medication, increasing the risk of relapse into psychosis, so adherence education is crucial.

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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

A nurse is caring for a school-age client in an outpatient clinic. Exhibits The nurse should identify which of the client findings are manifestations of a factitious disorder? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client?

Correct Answer is D

Explanation

A nurse is caring for a client who has factitious disorder. The client states, "I am so tired of living like this. Maybe I should just end it all." Which of the following actions should the nurse take?

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A nurse is planning discharge for a client who has schizophrenia and reports "I don't have a place to live." Which of the following referrals should the nurse request from the provider?

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