The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

Assessment of the lower extremities

Assessment of the posterior thorax

Assessment of the abdomen

Assessment of the genitalia and rectum

Answer and Explanation

The Correct Answer is D

Given the traumatic nature of sexual assault and the potential for re-traumatization, the assessment of the genitalia and rectum should be conducted last. This allows the nurse to build rapport with the client, establish trust, and address any immediate concerns or needs before proceeding with a potentially distressing examination.

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Correct Answer is D

Explanation

Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A. While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B. A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C. While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.

A. Ask the client to bring all the medications and supplements to an interview. B. Ask the caregiver whether the client is taking prescribed medications. C. Ask the client to identify which medications are taken every day D. Ask the client about the use of any over-the-counter medications.

Correct Answer is A

Explanation

Ask the client to bring all the medications and supplements to an interview involves direct visual confirmation of all medications and supplements the client is currently taking. It allows the nurse to verify the actual medications being used, including prescription medications from multiple providers, over-the-counter medications, and supplements.
B. While caregivers can provide valuable information about the client's medication regimen, relying solely on their input may not always be accurate.
C. While it provides information about daily medications, it may not capture medications taken on an as- needed basis or those prescribed intermittently.
D. Inquiring about over-the-counter medications is essential as they can interact with prescribed medications and affect the overall medication regimen. However, this method alone may not capture the entirety of the client's medication regimen, particularly prescription medications from multiple providers.

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The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

Correct Answer is D

Explanation

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

Correct Answer is A

Explanation

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