A nurse is caring for a client in the emergency department (ED). (Item 1/6)
Drag words from the choices below to fill in each blank in the following sentence.
The nurse should identify the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Client withdrawal of prior consent must be done in writing: While clients can withdraw consent, it does not always need to be done in writing, depending on the situation. Verbal withdrawal is often sufficient unless specified otherwise.
B. Clients can refuse to attend group therapy: Clients have the right to refuse treatments and therapies, including group therapy, unless they pose a direct threat to themselves or others. This is part of respecting client autonomy.
C. Clients who are involuntarily committed do not maintain access to legal counsel: Clients who are involuntarily committed still have the right to access legal counsel. They have the right to challenge their commitment and consult with an attorney.
D. Clients who have a severe mental illness cannot request a psychiatric advance directive: Clients, regardless of the severity of their mental illness, can request a psychiatric advance directive. This document helps ensure that their treatment preferences are known if they are unable to communicate them during a crisis.
Correct Answer is A
Explanation
A. "The night shift nurse is terrible.": This is an example of displacement, where the client redirects feelings of anger or frustration from a more significant issue, such as personal conflict or stress, onto an unrelated person like the night shift nurse.
B. "If I do what I am supposed to do, it will go away.": This statement reflects an attempt at problem-solving or avoidance rather than displacement. The client is trying to manage the situation directly by taking action, rather than transferring emotions.
C. "I am so angry with my spouse.": This is a direct acknowledgment of the source of the distress (the spouse) and does not involve displacement. The client is openly expressing anger rather than redirecting it onto someone or something unrelated.
D. "I don't know why I am here in the first place.": This reflects denial, where the client avoids recognizing the true reasons for being in treatment. The client is avoiding confronting their feelings or the situation but isn’t displaying displacement.
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