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
This indicates that the client has a fluid volume deficit, which is consistent with the signs and symptoms of low urine output, weight gain, irritability, and headache. The normal range for serum osmolality is 275 to 295 mOsm/Kg.
Choice A is wrong because hemoglobin 15.3 mg/dL is within the normal range of 12 to 18 mg/dL and does not correlate with fluid imbalance.
Correct Answer is C
Explanation
This is because renal calculi can cause renal colic, which is a sudden and intense pain in the flank area that radiates to the groin or testicles.
The pain is caused by the stone obstructing the ureter and triggering spasms.
Choice A is wrong because a feeling of pressure in the bladder is more likely to indicate a lower urinary tract infection or an overactive bladder.
Choice B is wrong because a mild, burning pain when urinating is more likely to indicate a urinary tract infection or a urethral injury.
Choice D is wrong because a constant, dull, aching pain in the right upper quadrant is more likely to indicate a liver or gallbladder problem.
Normal ranges for urine pH are 4.5 to 8.0, and for specific gravity are 1.005 to 1.030.
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