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 C
Explanation
A. "Dwelling on these struggles will not help you move past your loss.": This response dismisses the client’s feelings and may minimize their grief. Acknowledging their emotions is important for therapeutic communication, and telling the client to stop dwelling may feel invalidating.
B. "Everyone struggles with loss, but you'll be okay in time.": While this response is intended to offer comfort, it may sound dismissive and could undermine the client’s grief experience. Each person processes loss differently, and it's important to acknowledge their feelings.
C. "Attending a support group may help both you and your partner.": This response is supportive and practical. It acknowledges that grief affects both individuals in a relationship and suggests a helpful resource. Support groups provide validation and connection with others going through similar experiences.
D. "Spend more time focusing on your relationship with your partner.": This response oversimplifies the situation and does not acknowledge the depth of the client’s grief. It may feel directive and might not address the underlying emotional need.
Correct Answer is C
Explanation
A. Secure the client in bed by tightly tucking in sheets: Tightly tucking sheets is not an appropriate use of restraints and may increase the risk of injury. Restraints should be applied according to proper guidelines, and they should allow the client to move as much as is safe.
B. Obtain a prescription to renew the restraint prescription every 48 hr: Restraint prescriptions must be renewed every 24 hours, not every 48 hours, to ensure ongoing assessment of the client's need for restraints.
C. Document the interventions used before applying restraints: It is important to document all interventions attempted before applying restraints. This includes any less restrictive measures that were tried and failed before restraints were applied, in line with best practices and legal requirements.
D. Delegate assistive personnel to check on the client regularly: While assistive personnel can help with monitoring, the nurse is ultimately responsible for ensuring the client is checked on regularly and for assessing the safety and well-being of the client in restraints.
Complete the following sentence by using the lists of options.
The client is at risk of developing