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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Aching leg: This is not a common issue related to gastric endoscopy and is not typically addressed as a post-procedure concern.
B. Sore throat: This is a common post-procedure symptom due to the insertion of the endoscope through the mouth and throat. Providing throat lozenges or warm saline gargles can help alleviate this discomfort.
C. Nausea: Although nausea can occur after a procedure, it is less common than a sore throat after gastric endoscopy. Monitoring and treating nausea is important but not as specific to the procedure as a sore throat.
D. Headache: A headache is not a typical post-procedure issue for a gastric endoscopy and is less relevant to this procedure than sore throat.
Correct Answer is B
Explanation
A. Change to less anxiety-promoting questions: This is not the immediate priority as the client's behavior requires intervention for safety and propriety.
B. State it is unacceptable to undress during the interview: Addressing the behavior directly helps set boundaries and maintain appropriate conduct in the therapeutic setting.
C. Leave the client's room so she can act out her anxiety: Leaving the room does not address the immediate inappropriate behavior and could exacerbate the situation.
D. Ignore the client's inappropriate behavior: Ignoring the behavior may not manage the situation effectively and can lead to further escalation.
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