Which of the following actions should the nurse take first when performing an assessment on a client who reports being sexually assaulted?

Document the client's verbatim statements.

Ask the client for permission to take photographs.

Determine any physical signs of injury.

Provide community sexual assault support contacts.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Documenting the client's verbatim statements is crucial for legal purposes and for ensuring that the client's experience is accurately recorded. However, this is not the first action to take. The nurse must first address any immediate medical concerns, which include identifying and treating injuries.

Choice B reason:

Asking for permission to take photographs is an important part of collecting evidence, but it should be done after addressing immediate health concerns and with the client's consent. It is also essential that this step is performed in a sensitive and non-judgmental manner.

Choice C reason:

Determining any physical signs of injury is the most critical initial step. The nurse must assess for injuries that may require immediate intervention. This aligns with the priorities of care in emergency nursing, which focus on stabilizing the patient's condition and addressing urgent health issues.

Choice D reason:

Providing community sexual assault support contacts is an important aspect of holistic care and ensures that the client has access to ongoing support. However, this action follows after immediate health concerns have been addressed and should be part of the long-term care plan.

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Correct Answer is D

Explanation

Choice A Reason:

The laissez-faire leadership style is characterized by a hands-off approach, where the leader provides little to no direction and allows group members to make decisions. In this scenario, the nurse is not taking a laissez-faire approach; instead, she is actively engaging the group to discuss and resolve the issue.

Choice B Reason:

Surrogate leadership is not a widely recognized leadership style in nursing. It typically refers to a situation where someone acts on behalf of another, but in the context of leadership styles, it does not apply. Therefore, this choice is not relevant to the given scenario.

Choice C Reason:

Autocratic leadership involves the leader making decisions unilaterally without input from group members. This style is characterized by clear, direct communication and control over decision-making. The nurse's action of asking the group for input indicates that she is not employing an autocratic style.

Choice D Reason:

Democratic leadership is marked by participative decision-making, where the leader includes group members in the process to encourage collaboration and consensus-building. By asking the group for their thoughts on resolving the bathroom cleanliness issue, the nurse is demonstrating democratic leadership, which values the input and engagement of all group members.

A. "I haven't gotten my period yet, and all my friends have theirs." B. "There's a big pimple on my face, and I worry that everyone will notice it." C. "My parents treat me like a baby sometimes." D. "None of the kids at this school like me, and I don't like them either."

Correct Answer is D

Explanation

Choice A Reason:

The comment "I haven't gotten my period yet, and all my friends have theirs" reflects a common concern among adolescents regarding physical development and peer comparison. While this can cause anxiety, it is generally a normal part of adolescent development. The nurse can reassure the adolescent that the timing of puberty varies widely and that it is normal to develop at a different pace than peers.

Choice B Reason:

The concern about a pimple on the face, "There's a big pimple on my face, and I worry that everyone will notice it," is typical of adolescent worries about appearance and self-esteem. While it is important to address these concerns and provide support, it is not as urgent as addressing potential social isolation or mental health issues.

Choice C Reason:

The statement "My parents treat me like a baby sometimes" indicates a common struggle for independence among adolescents. This issue can be addressed through family counseling and communication strategies to help the adolescent and parents navigate this developmental stage. However, it does not indicate an immediate risk to the adolescent's well-being.

Choice D Reason:

The comment "None of the kids at this school like me, and I don't like them either" is the most concerning and should be the nurse's priority. This statement suggests social isolation and potential feelings of depression or low self-esteem. Social isolation can have significant negative impacts on an adolescent's mental health and development. It is crucial for the nurse to explore this further, provide support, and possibly refer the adolescent to a mental health professional.

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Which of the following actions should the nurse take first when performing an assessment on a client who reports being sexually assaulted?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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