A young woman arrives to the Emergency Department and reports that she was raped and stabbed.
What should the nurse do first?
Call the Sexual Nurse Examiner.
Assess vital signs.
Call her parents to ask for permission to treat.
Contact Security in case the perpetrator arrives.
The Correct Answer is B
The nurse should prioritize the physical safety and stability of the patient who has been raped and stabbed.
Assessing vital signs is the first step in determining the patient’s condition and identifying any life-threatening injuries that need immediate intervention.
Choice A is wrong because calling the Sexual Nurse Examiner is not the first action to take.
The Sexual Nurse Examiner is a specially trained nurse who can perform a forensic examination and collect evidence from the patient, but this should be done after ensuring the patient’s physical safety and obtaining consent.
Choice C is wrong because calling her parents to ask for permission to treat her is not necessary or appropriate.
The patient is an adult who can consent to her own treatment unless she is incapacitated or mentally incompetent.
Calling her parents without her permission may violate her privacy and autonomy.
Choice D is wrong because contacting Security in case the perpetrator arrives is not the most urgent action to take.
The nurse should focus on the patient’s needs and not assume that the perpetrator will follow her to the hospital.
Security measures can be taken later if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.
Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.
They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.
Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.
Correct Answer is A
Explanation
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.