Strategy Session: Client Need 3

Psychosocial Integrity

Question Type: Implementation
Strategy Used: Appropriate vs. Inappropriate

Consider this example:

The nurse is caring for a woman who states that she was beaten and sexually assaulted by a male friend. What should the nurse do first?

(1)		encourage the client to call her lawyer.

(2)		ask for a psychiatry consult.

(3)		stay with the client during the physical exam.

(4)		wash and dress the client's wounds before the physical exam.

Applying the strategy: First, reword the question in your own words. What is the most important initial nursing action to take with a sexual assault victim? Next, determine what is appropriate and what is inappropriate. Answer choice 1: Certainly not the first action the nurse should take with this client. Answer choice 2: Nurse should not initiate a psychiatry consult. Answer choice 3: This provides consistent emotional and physical support for the client. Answer choice 4: Contraindicated. This eradicates potential evidence. What's the most appropriate behavior? The correct answer is (3). This is clearly the nursing action that is most appropriate in this situation.

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