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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "We will help get you through this. You'll be fine.": While this statement may be meant to comfort, it dismisses the client's feelings and doesn't address the possibility of immediate harm or crisis. It’s important to validate the client’s emotions and assess for safety.

B. "What have you done to change your situation?": This response can come across as accusatory or judgmental, which may not be helpful in a crisis situation. It’s important to be supportive and nonjudgmental rather than questioning the client’s actions.

C. "Are you thinking about harming yourself?": The client's statement indicates feelings of hopelessness, which could signal suicidal ideation. Directly asking about self-harm or suicide helps assess the client's safety and provides an opportunity to intervene if necessary.

D. "You should remove yourself from this situation now.": While suggesting safety is important, this statement may feel too directive or overwhelming. The nurse should assess the client’s readiness for action and help them explore their options in a supportive way.

A. "I do not see myself attending community support groups" B. "My drinking isn't as bad as everyone says it is." C. "My family has a history of alcohol use disorder." D. "I was diagnosed because my spouse is upset about my drinking

Correct Answer is C

Explanation

A. "I do not see myself attending community support groups": This indicates resistance to accepting the diagnosis. Participation in community support groups, such as Alcoholics Anonymous, is often an important part of treatment and recovery for alcohol use disorder.
B. "My drinking isn't as bad as everyone says it is.": This statement reflects denial, a common defense mechanism in individuals with alcohol use disorder. It shows a lack of acceptance and an unwillingness to acknowledge the severity of the problem.
C. "My family has a history of alcohol use disorder": This indicates acceptance of the diagnosis as the client is acknowledging the familial connection and potential genetic predisposition to alcohol use disorder. It shows insight into the condition and a willingness to consider its impact.
D. "I was diagnosed because my spouse is upset about my drinking": This statement shifts the responsibility for the diagnosis onto the spouse and does not show acceptance of the disorder. It suggests that the client may not fully accept the diagnosis as their own issue.

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Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

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