The nurse who 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?

A Report the incident to the university's security department.

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

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

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

Answer and Explanation

The Correct Answer is D

A. Reporting the incident to the university's security department is an important step but not the immediate priority. The primary focus in the emergency department is to preserve forensic evidence for legal purposes.
B. While understanding the client's personal reaction is important for providing emotional support, it does not take precedence over the immediate need to preserve evidence.
C. Listening to the client’s description of the event is part of the process, but preserving evidence is more critical. The main goal during the examination is to collect and document physical evidence rather than focusing on the details of the event.
D. Ensuring the client does not shower is crucial as it preserves physical evidence from the assault, which is essential for the investigation and legal proceedings.

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Correct Answer is D

Explanation

A. Apply an internal fetal heart monitor: This action might be necessary if there are concerns about the accuracy of fetal heart rate monitoring, but it is not the immediate priority.
B. Notify the healthcare provider: While the provider will need to be informed of the situation, the most critical initial step involves addressing the decrease in the fetal heart rate.
C. Use a vibroacoustic stimulator: This is used to stimulate fetal movement and evaluate fetal heart rate response. However, if there is a significant concern about fetal distress, the priority is to provide oxygen.
D. Administer oxygen via face mask: Providing supplemental oxygen can help improve fetal oxygenation and counteract the effects of the decreased fetal heart rate after contractions, making it the most immediate and effective intervention.

A. Explain that living wills cannot be followed by emergency personnel. B. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet. C. Seek clarification of the type of advance directive the client has. D. Schedule a client and family conference to review the plan of care.

Correct Answer is C

Explanation

A. Explain that living wills cannot be followed by emergency personnel: This statement is incorrect. Living wills can be followed in emergencies, but they need to be reviewed to understand the specifics of the client’s wishes.
B. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: While checking for a DNR bracelet is important, it is more appropriate to clarify the type of advance directive or living will the client has, as there might not always be a visible DNR bracelet.
C. Seek clarification of the type of advance directive the client has: It is essential to clarify the specific type of advance directive or living will the client has to determine if it includes instructions for resuscitation or other emergency measures. This approach addresses the family’s concern and aligns care with the client’s wishes.
D. Schedule a client and family conference to review the plan of care: While important, this action is more long-term and does not immediately address the current question about the living will’s directives.

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The nurse who 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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