A nurse is preparing to discharge a client who was treated for sexual assault. Prior to discharge, which of the following actions should the nurse plan to take?
Provide the client with grooming supplies and a private area to bathe.
Call the client's home for someone to pick up the client
Retain the client's cell phone for evidence.
Send the client's clothes to the laundry before returning the items to the client.
The Correct Answer is A
A. Provide the client with grooming supplies and a private area to bathe: After evidence collection and medical treatment are complete, allowing the client to bathe in privacy supports their dignity and helps restore a sense of control. This is a therapeutic and appropriate step prior to discharge.
B. Call the client's home for someone to pick up the client: Contacting someone without the client's consent could breach confidentiality and potentially endanger the client, especially if the assailant lives in the same household.
C. Retain the client's cell phone for evidence: The nurse does not have the authority to confiscate personal property like a cell phone. Evidence collection must follow legal protocols, typically involving law enforcement and forensic teams.
D. Send the client's clothes to the laundry before returning the items to the client: The client's clothing may be part of the forensic evidence. Washing or returning them before proper processing would compromise the legal chain of custody.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Acetone breath: Acetone (fruity-smelling) breath is a hallmark of diabetic ketoacidosis (DKA), not HHS. It results from ketone production due to fat breakdown, which is typically absent in HHS.
B. Fever: Fever may indicate underlying infection, which is a common trigger for HHS in older adults. Infections raise stress hormone levels, worsening insulin resistance and contributing to severe hyperglycemia.
C. 68 years of age: HHS most commonly affects older adults, typically those with type 2 diabetes. Advanced age is a significant risk factor due to impaired thirst mechanisms and decreased kidney function.
D. Serum glucose 800 mg/dL (74 to 105 mg/dL): HHS is characterized by extremely high blood glucose levels, often exceeding 600 mg/dL. A level of 800 mg/dL is consistent with the severe hyperglycemia seen in HHS.
E. Serum bicarbonate 15 mEq/L (21 to 28 mEq/L) Insidious onset: While bicarbonate levels in HHS may be mildly decreased, they are usually higher than in DKA. An insidious (gradual) onset with progressive symptoms over days is typical of HHS and differentiates it from the rapid onset of DKA.
Correct Answer is A
Explanation
A. Notify the rapid response team due to the client’s clinical signs of a tension pneumothorax: The client presents with acute right-sided chest pain, dyspnea, hypotension, unilateral decreased breath sounds, hyperresonance, and agitation—classic signs of a tension pneumothorax, a life-threatening emergency requiring immediate intervention. Rapid response activation ensures rapid access to advanced airway and chest decompression support.
B. Reassure the client and administer prescribed analgesics for pain relief: The pain is a symptom of a serious underlying condition—possibly a collapsed lung. Administering pain medication could delay life-saving intervention.
C. Encourage the client to take deep breaths and use incentive spirometry: This intervention is appropriate for postoperative atelectasis, but it is contraindicated in tension pneumothorax. Increasing intrathoracic pressure through deep breaths may worsen the pneumothorax.
D. Elevate the head of the bed and increase oxygen to 4 L/min via nasal cannula: While increasing oxygen and elevating the head can help improve oxygenation, they do not treat the underlying cause. These supportive measures may be used after emergency intervention has been initiated.
E. Document the findings and re-evaluate in 15 minutes: Delaying intervention in this situation is unsafe. A tension pneumothorax can rapidly lead to cardiovascular collapse, so waiting even a few minutes may result in deterioration or death.
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