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

Victims of intimate partner violence require access to resources and support services to help them navigate their situation and make informed decisions about their safety and well-being.
A. Blaming the victim for the violent behavior of their partner is not only ineffective but also unethical.
B. While providing strategies for interacting with others in social situations may be helpful for general social skills development, it is not directly relevant to addressing the immediate needs of victims of intimate partner violence.
C. Instructing the client on ways to behave to prevent making their partner angry is not appropriate. It implies that the victim is responsible for the abusive behavior of their partner, which is not the case.

A. Begins to discuss how their partner and children are important to them B. Asks to change the topic during the interview process C. Discusses reasons for making a behavior change D. Requests more information about treatment options

Correct Answer is C

Explanation

Discussing the client's reasons for change is a key component of eliciting and strengthening motivation. When the client voluntarily discusses their reasons for making a behavior change, it suggests that they are beginning to articulate and explore their motivations.

A. This behavior indicates successful engagement with the client.

B. This behavior may indicate resistance or ambivalence toward discussing the target behavior change.

D. This behavior may indicate a readiness to explore treatment options but does not necessarily indicate successful engagement with the client in MI.

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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 in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?

Correct Answer is D

Explanation

A nurse is interviewing a client who is contemplating a behavior change. According to the processes of Motivational Interviewing, which of the following client behaviors indicates that the nurse has successfully engaged with the client?

Correct Answer is C

Explanation

A home health nurse cares for a neighborhood of diverse clients. Which of the following aspects of cultural diversity should the nurse remember when caring for the clients?

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

A nurse is using a medical interpreter to communicate with a client. Which of the following actions should the nurse take?

A nurse is using the Cultural Formulation Interview (CFI) tool while collecting a health history from a client who is from a culture different than the nurse. Which of the following statements should the nurse make?

A 35-year-old woman has been admitted to the hospital for a hysterectomy secondary to uterine cancer caused by smoking, and the nurse is collecting subjective data prior to surgery. Which statements by the nurse could be construed as non-judgmental? (Select All that Apply.)

A nurse is providing care to a client who asks, "What is the meaning of holistic nursing care?" The nurse should give which of the following responses?

A nurse is asking a client who has schizophrenia about their cultural and spiritual beliefs. Which of the following is the purpose for collecting this information?