A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

Instruct the client to shower and change their clothes.

Ask the client for details about the assault.

Reassure the client that their injuries are not life-threatening.

Limit the number of staff members providing care for the client.

Answer and Explanation

The Correct Answer is D

Choice A reason: Instructing the client to shower and change clothes is inappropriate, as it may destroy forensic evidence critical for legal proceedings. Evidence preservation is a priority post-sexual assault, and showers are delayed until after forensic examination, making this intervention incorrect and potentially harmful.
Choice B reason: Asking for details about the assault can retraumatize the client and is not the nurse’s role immediately post-assault. Trained forensic examiners or counselors handle such discussions sensitively. This action risks emotional harm and is inappropriate for initial care, making it incorrect.
Choice C reason: Reassuring the client that injuries are not life-threatening may minimize their trauma and emotional distress. The focus should be on emotional support and safety, not downplaying injuries, which may be perceived insensitively. This intervention is inappropriate for trauma-informed care, making it incorrect.
Choice D reason: Limiting staff members providing care reduces the client’s exposure to multiple providers, minimizing retraumatization and ensuring consistency. This trauma-informed approach fosters trust and safety post-sexual assault, aligning with best practices for psychological support, making it the correct intervention.

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Correct Answer is B

Explanation

Choice A reason: Assigning all staff to the emergency department disrupts care for existing inpatients and may overwhelm ED operations. Staff allocation should follow a triage plan, balancing hospital-wide needs. This action is impractical and risks neglecting other patients, making it less effective than preparing resources.
Choice B reason: Preparing to discharge stable clients frees up beds for incoming casualties, optimizing hospital capacity during a mass casualty event. This aligns with disaster protocols, ensuring resources are available for critical patients. It supports efficient triage and care delivery, making it the correct action.
Choice C reason: Canceling all elective surgeries immediately is premature without assessing the event’s scope. Some surgeries may continue if resources allow, per disaster protocols. This action disrupts hospital operations unnecessarily and is less urgent than preparing beds for casualties, making it inappropriate.
Choice D reason: Requesting ventilators assumes specific needs without assessing the casualty event’s nature. Ventilators may not be immediately required, and resource allocation should follow triage protocols. Preparing beds is a more immediate and versatile action, making this choice less prioritized in the initial response.

A. Place the client upright on a donut-shaped cushion. B. Turn and reposition the client every 15 minutes while sitting. C. Apply a moisture-barrier cream to the affected area. D. Turn and reposition the client every 3 hours while in bed.

Correct Answer is C

Explanation

Choice A reason: Using a donut-shaped cushion is not recommended, as it can increase pressure on surrounding tissues, worsening ischemia in the ischial area. Nonblanchable erythema indicates early pressure injury, requiring pressure relief and skin protection. This intervention risks further tissue damage, making it inappropriate for managing the client’s condition.
Choice B reason: Repositioning every 15 minutes while sitting is excessive and impractical, potentially causing discomfort or skin shear. For paraplegic clients, repositioning every 1-2 hours while sitting, combined with pressure-relieving cushions, prevents progression of nonblanchable erythema. This frequency is not evidence-based for pressure injury prevention, making it incorrect.
Choice C reason: Applying moisture-barrier cream protects the skin from breakdown in the presence of nonblanchable erythema, an early stage of pressure injury. For paraplegic clients, who are at high risk due to immobility, this intervention reduces moisture-related damage and supports skin integrity, aligning with evidence-based pressure injury prevention strategies.
Choice D reason: Repositioning every 3 hours in bed is insufficient for a paraplegic client with nonblanchable erythema, as guidelines recommend every 2 hours to relieve pressure. Prolonged pressure risks advancing tissue damage, especially in high-risk areas like the ischium. This intervention is inadequate for preventing pressure injury progression.

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A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Correct Answer is C

Explanation

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