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.

None

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 death of a client's father two months ago, while significant, is not directly indicative of conduct disorder. Conduct disorder is characterized by a pattern of behavior that violates the rights of others or major societal norms. While a traumatic event like the death of a parent can impact a child's behavior, it is not a diagnostic criterion for conduct disorder.

Choice B Reason:

Experiencing frequent facial tics is more commonly associated with Tourette syndrome or other tic disorders, rather than conduct disorder. Conduct disorder involves behaviors such as aggression, theft, vandalism, and serious violations of rules, rather than physical tics.

Choice C Reason:

Adhering strictly to routines is a behavior more commonly associated with obsessive-compulsive disorder (OCD) or autism spectrum disorder (ASD). Conduct disorder is characterized by behaviors that are oppositional and defiant, rather than a need for strict routines.

Choice D Reason:

Being suspended from school several times in the past year is a behavior consistent with conduct disorder. This disorder is marked by a pattern of disruptive and rule-breaking behaviors, including aggression, deceitfulness, and serious violations of rules. Frequent suspensions from school indicate ongoing behavioral issues that align with the diagnostic criteria for conduct disorder.

A. Valproate (Depakote) B. Carbamazepine (Tegretol) C. Lithium (Eskalith)

Correct Answer is ["A"]

Explanation

Choice A Reason:

Valproate (Depakote) is a mood stabilizer commonly used in the treatment of bipolar disorder. It helps to control manic and mixed episodes and can also prevent the recurrence of these episodes. Valproate works by increasing the levels of gamma-aminobutyric acid (GABA) in the brain, which has a calming effect on nerve activity.

Choice B Reason:

Carbamazepine (Tegretol) is another mood stabilizer that is effective in treating manic episodes in bipolar disorder. It is particularly useful in individuals with rapid cycling bipolar disorder and those who have not responded well to lithium. Carbamazepine works by decreasing nerve impulses that cause seizures and pain, which also helps to stabilize mood.

Choice C Reason:

Lithium (Eskalith) is one of the most well-known and frequently prescribed medications for bipolar disorder. It is effective in reducing the severity and frequency of mania and may also help to alleviate or prevent bipolar depression. Lithium is thought to work by stabilizing the cell membranes and influencing the synthesis and release of certain neurotransmitters.

Non-Selected Choices Reason:

Donepezil (Aricept) is not used for bipolar disorder; it is used to treat symptoms of Alzheimer's disease. Paroxetine (Paxil) is an SSRI antidepressant that may be used to treat depressive episodes in bipolar disorder, but it is not a primary treatment for bipolar disorder itself and must be used cautiously to avoid inducing mania.

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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 ["A"]

Explanation

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