A nurse is caring for a client who was sexually assaulted. An assessment of the client indicates that they might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?
Where did the assault occur?
Do you give us permission to call the police?
Who was the individual who assaulted you?
What day and time did the assault take place?
The Correct Answer is C
A. While knowing the location of the assault may be relevant for police reports, it does not directly pertain to the client’s health and potential exposure to HIV.
B. Permission to contact the police is important for legal reasons, but the priority is to address the client's health needs first.
C. Identifying the individual who assaulted the client is critical for assessing the risk of HIV exposure and determining the need for post-exposure prophylaxis (PEP). This question directly impacts the client’s immediate health care.
D. Understanding the day and time of the assault is useful for legal documentation but is less critical than assessing potential exposure to HIV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F","G"]
Explanation
D. Measure lactate level: Elevated lactate levels are a strong indicator of sepsis and can help guide treatment.
E. Administer broad-spectrum antibiotics: Prompt administration of antibiotics is crucial to combat the infection.
F. Rapidly administer 30 mL/kg of normal saline: Aggressive fluid resuscitation is necessary to improve blood pressure and tissue perfusion.
G. Obtain blood cultures: Blood cultures can help identify the specific organism causing the infection and guide antibiotic therapy.
Other interventions that may be considered, but not necessarily within the first hour, include:
A. Obtain a urine specimen: This can help identify a urinary tract infection as a potential source of sepsis.
B. Insert a nasogastric tube: This may be necessary if the client is unable to tolerate oral intake or requires gastric decompression.
C. Type and cross-match for 2 units of packed RBCs: This may be necessary if the client develops significant anemia or requires blood transfusion.
Correct Answer is B
Explanation
A. Flushing of the skin is not typical in hypovolemic shock; rather, the skin is usually cool and clammy due to vasoconstriction.
B. Oliguria, or decreased urine output, is expected in hypovolemic shock as the kidneys receive less blood flow, leading to reduced urine production.
C. Bradypnea is not a common finding in hypovolemic shock; instead, tachypnea (increased respiratory rate) is typically observed due to compensatory mechanisms for hypoxia and acidosis.
D. Hypertension is not expected in hypovolemic shock; instead, the client typically presents with hypotension due to decreased blood volume and pressure.
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