A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
Conduct a pregnancy test.
Request a mental health consultation for the client.
Offer prophylactic medication to prevent STIS.
Provide a trained advocate to stay with the client.
The Correct Answer is D
The nurse should provide a trained advocate to stay with the client, as this can help reduce the psychological trauma and provide emotional support and information to the client. The other options are also important, but they can be done later or after obtaining the client's consent.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This question helps the nurse to evaluate the client's personal coping skills and identify their strengths and weaknesses. Asking about the impact of the situation, the current feelings, or the future outlook are not directly related to coping skills, although they might provide some useful information.
Correct Answer is A
Explanation
The correct answer is:
A. Implement continuous one-to-one observation.
Choice A reason:
Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.
Choice B reason:
While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.
Choice C reason:
Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.
Choice D reason:
Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.
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