The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

Listen attentively to the client's description of the event.

Report the incident to the university's security department.

Do not allow client to shower until all evidence is obtained.

Determine the client's personal reaction to the reported rape.

Answer and Explanation

The Correct Answer is C

A.   Listen attentively to the client's description of the event. While important for providing emotional support, it is secondary to preserving forensic evidence.
B.   Report the incident to the university's security department. This is necessary but not as immediately critical as preserving evidence.
C.   Do not allow client to shower until all evidence is obtained. Preserving evidence is the highest priority in this situation to ensure a thorough forensic investigation and legal process.
D.   Determine the client's personal reaction to the reported rape. Understanding the client's emotional state is important for providing support, but it should be done after ensuring that critical forensic evidence is collected.

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Correct Answer is D

Explanation

A. A blood glucose level of 90 mg/dL is within the normal reference range of 74 to 106 mg/dL, so it is not a concern.
B. A potassium level of 4 mEq/L is also within the normal reference range of 3.5 to 5.0 mEq/L, so it does not need to be reported.
C. Although the hemoglobin level of 13 g/dL is below the reference range provided, it is not critically low and may not be urgent unless the patient has symptoms of anemia or other related issues.
D. A serum creatinine level of 5 mg/dL is significantly higher than the normal reference range of 0.5 to 1.1 mg/dL. This indicates renal impairment, which could affect the patient's ability to clear medications used during surgery and could lead to postoperative complications. Therefore, it is crucial to report this finding to the surgeon immediately.

A. Assist the client with clarifying values about end-of-life care options. B. Ask the client how often episodes of sundowning are experienced. C. Request to have the client lie as still as possible for the assessment. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.

B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.

C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.

D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.

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Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
, dropdown
 and dropdown

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The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

Correct Answer is D

Explanation

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

To auscultate for a carotid bruit, the nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location.)

Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.