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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 A

Explanation

A. "The night shift nurse is terrible.": This is an example of displacement, where the client redirects feelings of anger or frustration from a more significant issue, such as personal conflict or stress, onto an unrelated person like the night shift nurse.
B. "If I do what I am supposed to do, it will go away.": This statement reflects an attempt at problem-solving or avoidance rather than displacement. The client is trying to manage the situation directly by taking action, rather than transferring emotions.
C. "I am so angry with my spouse.": This is a direct acknowledgment of the source of the distress (the spouse) and does not involve displacement. The client is openly expressing anger rather than redirecting it onto someone or something unrelated.
D. "I don't know why I am here in the first place.": This reflects denial, where the client avoids recognizing the true reasons for being in treatment. The client is avoiding confronting their feelings or the situation but isn’t displaying displacement.

A. Secure the client in bed by tightly tucking in sheets. B. Obtain a prescription to renew the restraint prescription every 48 hr. C. Document the interventions used before applying restraints. D. Delegate assistive personnel to check on the client regularly.

Correct Answer is C

Explanation

A. Secure the client in bed by tightly tucking in sheets: Tightly tucking sheets is not an appropriate use of restraints and may increase the risk of injury. Restraints should be applied according to proper guidelines, and they should allow the client to move as much as is safe.
B. Obtain a prescription to renew the restraint prescription every 48 hr: Restraint prescriptions must be renewed every 24 hours, not every 48 hours, to ensure ongoing assessment of the client's need for restraints.
C. Document the interventions used before applying restraints: It is important to document all interventions attempted before applying restraints. This includes any less restrictive measures that were tried and failed before restraints were applied, in line with best practices and legal requirements.
D. Delegate assistive personnel to check on the client regularly: While assistive personnel can help with monitoring, the nurse is ultimately responsible for ensuring the client is checked on regularly and for assessing the safety and well-being of the client in restraints.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a personality disorder. Which of the following statements made by the client indicate they are coping with the maladaptive defense mechanism of displacement?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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