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?

Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.

Cardiovascular

Monitor vital signs continuously

The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.

Provide warmth

Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.

Respiratory

Assess lung sounds

The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.

Chest x-ray

Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.

1. Poor personal hygiene

- Neglect: X

Rationale: Poor personal hygiene indicates neglect, as the caregiver is not providing adequate care for the client's basic needs.

2. Over sedation

- Physical abuse: X

Rationale: Over sedation is consistent with physical abuse because it involves administering medication to subdue the client, potentially to control or silence them.

3. Bruises in various stages of healing

- Physical abuse: X

Rationale: Bruises in various stages of healing are a sign of physical abuse, indicating that the client has been physically harmed multiple times over a period.

4. Depression or withdrawn behavior

- Mistreatment: X

Rationale: Depression or withdrawn behavior can be a result of mistreatment, which includes emotional and psychological abuse, leading to social isolation and emotional distress.

5. Untreated pressure injuries

- Neglect: X

Rationale: Untreated pressure injuries are a clear sign of neglect, as the caregiver is failing to provide necessary medical care to prevent and treat these injuries.

6. Leaving an older adult in a public space

- Mistreatment:

Rationale: Abandonment, which is a form of mistreatment, involves leaving the older adult in a public space without care or supervision.