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 B
Explanation
According to the Addiction Nursing Competencies, antisocial personality traits are one of the risk factors for developing addictive behaviors.
Antisocial personality disorder is characterized by a disregard for the rights and feelings of others, impulsivity, deceitfulness, and lack of remorse.
Choice A is wrong because high self-esteem is not associated with addictive behaviors. On the contrary, low self-esteem, passivity, and inability to relax or defer gratification are some of the personality factors that can predispose a person to substance use disorders.
Choice C is wrong because good communication skills are not related to addictive
behaviors. In fact, poor communication skills, social isolation, and lack of support are some of the psychosocial factors that can contribute to substance use disorders.
Choice D is wrong because aggressive behaviors are not a specific indicator of addictive behaviors.
Aggression can be a result of various factors, such as frustration, anger, stress, or mental illness. Aggression can also be influenced by the type and amount of substance used.
Correct Answer is A
Explanation
Notify the health care provider to report and anticipate new orders.
This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.
A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.
Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.
Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.
The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.
Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.
The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.
Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.
Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.
The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).
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