Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.
Allow the client to shower prior to their genital examination.
Offer emergency contraception.
Initiate a prescription for an antidepressant.
Perform a rapid HIV test.
Collect and preserve evidence.
Administer sexually transmitted infection prophylaxis.
Document the assessment findings in written and photographic form.
Correct Answer : B,E,F,G
Rationale for correct choices:
- Offer emergency contraception: In cases of sexual assault, emergency contraception should be offered as soon as possible to prevent pregnancy. This is a standard part of care for survivors of sexual violence, ideally within 72 hours after the assault.
- Collect and preserve evidence: Collecting and preserving physical evidence is critical for legal and forensic purposes. This includes clothing, swabs, and other materials that may help in a potential investigation. The nurse should follow proper protocols to ensure evidence is preserved without contamination.
- Administer sexually transmitted infection prophylaxis: Given the risk of sexually transmitted infections (STIs) following sexual assault, prophylaxis should be provided immediately, especially for high-risk infections such as chlamydia, gonorrhea, and HIV.
- Document the assessment findings in written and photographic form: Proper documentation of the client's physical findings, including bruising, broken fingernails, and other injuries, is essential for both legal purposes and ongoing medical care.
Rationale for incorrect choices:
- Allow the client to shower prior to their genital examination: The client should not be allowed to shower or change clothes before the genital examination or evidence collection, as this could wash away important forensic evidence, such as bodily fluids or hair.
- Initiate a prescription for an antidepressant: While it is important to offer psychological support and follow-up care, prescribing an antidepressant should not be the immediate action. The client may require further assessment by a mental health professional to determine the most appropriate treatment.
- Perform a rapid HIV test: While HIV exposure is a concern after sexual assault, a rapid HIV test immediately following an assault will likely be negative as there is an incubation period (window period) before antibodies can be detected. Post-exposure prophylaxis (PEP) for HIV is the more appropriate immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "The honeymoon stage of violence usually gets longer over time": The honeymoon stage typically becomes shorter as the cycle of abuse progresses. Over time, the tension-building and abusive episodes tend to increase in frequency and intensity.
B. "Survivors of abuse often feel guilty": Survivors of intimate partner abuse often feel guilty, ashamed, or responsible for the abuse. They may believe they somehow provoked the violence or could have prevented it.
C. "As abuse continues, victims become more determined to be independent": Victims of abuse often become more dependent over time due to manipulation, fear, and control exerted by the abuser. They may find it difficult to leave or make independent decisions.
D. "Abusers often have high self-esteem": This statement is generally inaccurate as abusers often have low self-esteem and may use controlling behaviors as a way to mask feelings of inadequacy or insecurity.
Correct Answer is D
Explanation
A. Aspiration: Succinylcholine is used during electroconvulsive therapy (ECT) to induce muscle relaxation, but it does not specifically prevent aspiration. Aspiration risk is generally minimized by using an endotracheal tube and appropriate airway management during the procedure, not just succinylcholine.
B. Decreased heart rate: Succinylcholine is not used to manage heart rate. While ECT can cause heart rate fluctuations, other medications, like atropine, are typically used if bradycardia is a concern.
C. Elevated blood pressure: Succinylcholine does not address blood pressure regulation. ECT can cause temporary increases in blood pressure, but succinylcholine is used to relax muscles and does not manage blood pressure.
D. Muscle distress: Succinylcholine is given during ECT to relax muscles and prevent muscle contractions or "muscle distress" during the procedure. Without muscle relaxation, muscle contractions during the procedure could cause injury or severe discomfort.
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