The nurse is continuing to care for the client in the emergency department (ED). 

Exhibits

The nurse should monitor the client for which of the following based on the result of the client's laboratory test? Select all that apply.

A. A medication group: A medication group can help clients understand their medications, but it may not be the best for helping them adapt to the health care setting. Medication groups typically focus on pharmacological aspects rather than emotional or social adaptation.
B. A community meeting: A community meeting is an appropriate resource to help a newly admitted client adjust to the health care setting. These meetings allow clients to connect with others, learn about the structure of the facility, and share their experiences, which aids in their social and emotional adaptation.
C. A self-help meeting: Self-help meetings, such as those for addiction or mental health disorders, are useful for ongoing recovery, but they may not specifically help the client adapt to the new environment of a mental health facility.
D. A symptom-management group: While symptom-management groups can be helpful for clients to manage their mental health conditions, they do not specifically address adaptation to the healthcare setting, which is the primary need for a newly admitted client.

Rationale for correct choices:

• Fingernail assessment: Broken fingernails can be a sign of a struggle, as the client may have tried to defend themselves during the assault. Such injuries are commonly seen in cases of sexual assault, where victims may attempt to resist or protect themselves.
• Diagnostic results: The positive urine drug screen for GHB is key as it is often used as a "date rape drug" due to its ability to cause sedation, memory loss, and impaired judgment. Its presence supports the possibility of the client being drugged as part of a sexual assault.

Rationale for incorrect choices:

• Blood pressure: Blood pressure readings are typically not indicative of sexual assault. While anxiety or trauma can affect blood pressure, this measurement alone does not provide information directly related to sexual assault. Her BP is also within normal range.
• Abdominal examination: Mild tenderness in the abdomen could be incidental or related to other causes but is not directly linked to the typical findings in a sexual assault case. Abdominal examination would generally not be the primary assessment for identifying sexual assault unless there was significant trauma or injury to the abdomen.
• Temperature: A normal temperature of 37°C (98.6°F) does not indicate anything specific to sexual assault. While fever may occur in cases of infection, it is not a defining characteristic of sexual assault and doesn't help in confirming the occurrence.