A young female client is admitted to the emergency department because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client’s chief concern?

Client states, "My date raped me tonight."

Client claims that she was forced to participate in sexual intercourse.

Client has been sexually assaulted.

Client reported that she had sexual relations against her will.

Answer and Explanation

The Correct Answer is C

Choice A reason: Quoting “My date raped me tonight” is specific but may be too detailed for the chief concern, which should be concise and objective. “Sexually assaulted” is a clear, professional term that captures the event without verbatim quotes, making this less optimal for EMR documentation.

Choice B reason: “Claims” and “forced to participate” may imply doubt about the client’s report, which is untherapeutic and inappropriate. “Sexually assaulted” is a neutral, factual term that respects the client’s experience, making this choice less sensitive and incorrect for the chief concern documentation.

Choice C reason: Documenting “Client has been sexually assaulted” is concise, objective, and professional, accurately reflecting the chief concern without judgment or excessive detail. This aligns with trauma-informed care and EMR standards, making it the most appropriate choice for documenting the client’s reason for admission.

Choice D reason: “Sexual relations against her will” is vague and less precise than “sexually assaulted,” which is a recognized medical and legal term. This phrasing risks minimizing the assault, making it less appropriate and incorrect for clear, trauma-sensitive documentation in the EMR.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Identifying effective coping strategies is critical for an adolescent with suicidal ideation triggered by anger, as it addresses the root cause of the suicide attempt. This goal promotes emotional regulation and prevents future self-harm, aligning with psychiatric nursing priorities for suicide risk management.

Choice B reason: Attending group sessions supports socialization but does not directly address the client’s suicidal behavior or emotional triggers. Coping strategies are more critical to prevent recurrence of self-harm, making this goal less important than learning to manage feelings effectively in this context.

Choice C reason: Positive staff interaction fosters therapeutic alliance but does not target the client’s suicidal ideation or anger management. Developing coping skills is more critical to address the underlying emotional dysregulation, making this goal secondary to learning effective strategies for handling intense feelings.

Choice D reason: Expressing anger towards family may escalate conflict without resolving the client’s suicidal behavior. Teaching coping strategies is more important to manage emotions safely, preventing further self-harm. This goal is less therapeutic and potentially harmful, making it incorrect for priority care planning.

A. Mental status examination. B. History of substance use. C. Medication compliance. D. Motivation for treatment.

Correct Answer is A

Explanation

Choice A reason: A mental status examination (MSE) assesses cognition, mood, and thought processes, providing critical data on distractibility and concentration in a short timeframe. This guides the treatment plan for a client with these symptoms, aligning with psychiatric assessment protocols, making it the most important initial assessment.

Choice B reason: Substance use history is relevant but less urgent than an MSE, which directly evaluates current cognitive and emotional state. In 15 minutes, MSE provides immediate data for treatment planning, making substance history secondary and incorrect for the most critical initial assessment.

Choice C reason: Medication compliance informs treatment but does not address the client’s current distractibility and concentration issues as directly as an MSE. The MSE offers real-time insight into symptoms, guiding the plan, making compliance less urgent and incorrect for the primary assessment in this timeframe.

Choice D reason: Motivation for treatment is important but secondary to understanding the client’s current mental state via MSE, which informs immediate interventions for distractibility. Limited time prioritizes objective assessment, making motivation less critical and incorrect for the most important initial treatment planning step.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A young female client is admitted to the emergency department because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client’s chief concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mental health unit nurse completes the admission assessment for a depressed adolescent client with suicidal ideation. The client reports becoming angry with a sibling, so the client took a handful of pills. Which goal is most important for the nurse to establish with this client?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

A client with bipolar disorder tells the nurse about the need to make some deals to improve a retirement savings. Based on this information, which client outcome should the nurse include in the care?

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition?

The mother of an infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

The nurse is assessing a client with paranoia. Which behavior can this client be expected to exhibit?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?