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The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?
- A. Encouraging the patient to gain a sense of control over his or her life
- B. Collecting sufficient evidence to secure a criminal conviction
- C. Helping the patient understand that this will not happen again
- D. Encouraging the patient to verbalize what happened during the assault
Correct Answer: A
Rationale: Nursing interventions post-sexual assault focus on empowering the patient to regain control, prioritizing emotional recovery over legal outcomes, future safety guarantees, or forced verbalization.
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The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?
- A. Anxiety and denial
- B. Remorse and guilt
- C. Anger
- D. Grief
Correct Answer: B
Rationale: The family's blame and sense of responsibility indicate remorse and guilt, a stage of crisis where individuals process feelings of fault. This is distinct from anxiety, anger, or grief.
A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action?
- A. Apply a dressing saturated with chlorhexidine.
- B. Wash the bites with soap and water.
- C. Arrange for the patient to receive a hepatitis B vaccination.
- D. Assess the patient's immunization history.
Correct Answer: B
Rationale: Washing bites with soap and water after forensic documentation prevents infection. Chlorhexidine dressings, hepatitis B vaccination, or immunization history are not immediate priorities.
A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?
- A. Check the patient's blood glucose level.
- B. Assess for a documented history of major depression.
- C. Determine whether the patient has ingested a corrosive substance.
- D. Arrange for assessment of serum potassium levels.
Correct Answer: A
Rationale: Hypoglycemia can mimic alcohol intoxication symptoms like confusion and slurred speech, so checking blood glucose is critical. Depression, corrosive ingestion, or potassium levels are less likely mimics.
The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim?
- A. Respect the patient's privacy during assessment.
- B. Shave all pubic hair for laboratory analysis.
- C. Place items for evidence in plastic bags.
- D. Bathe the patient before the examination.
Correct Answer: A
Rationale: Respecting privacy minimizes trauma during a sexual assault assessment. Pubic hair is combed, not shaved; evidence goes in paper bags to avoid moisture; and bathing destroys evidence.
A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries?
- A. Myocardial infarction
- B. Hypoglycemia
- C. Hemorrhage
- D. Peritonitis
Correct Answer: C
Rationale: Cool, moist skin, tachycardia, and hypotension suggest hemorrhage, a common complication of femur fractures due to significant blood loss. MI, hypoglycemia, and peritonitis are less likely.