Which of the following questions is most important to ask a client who might have been exposed to HIV after being sexually assaulted?
Who was the individual who assaulted you?
What day and time did the assault take place?
Where did the assault occur?
Do you give us permission to call the police?
The Correct Answer is B
Choice A reason:
Asking about the identity of the assailant, while important for legal purposes, does not contribute to the immediate medical care of the client. The priority is to address potential health issues, such as exposure to HIV.
Choice B reason:
The timing of the assault is critical because it determines the eligibility for PEP. PEP should be initiated as soon as possible, ideally within 2 hours, but it can be effective up to 72 hours after exposure. Knowing the exact time of the assault helps healthcare providers act swiftly to mitigate the risk of HIV transmission.
Choice C reason:
While knowing where the assault occurred can provide context and may be relevant for legal proceedings, it does not influence the immediate medical treatment plan for potential HIV exposure.
Choice D reason:
Consent to involve law enforcement is a separate issue from medical treatment. While it's important to respect the client's wishes regarding reporting, it does not impact the decision-making process regarding HIV prophylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
The statement that the prosthesis will be adjustable depending on what shoe you are wearing is not accurate. Prostheses are custom-made to fit the individual and are not typically adjustable to different shoe types. The fit and alignment of the prosthesis are crucial for comfort and function, and these are not dependent on the footwear.
Choice B reason:
It is true that clients will need to do special exercises in advance of getting their prosthesis. These exercises are designed to strengthen the remaining limb and prepare the body for the use of a prosthesis. They are an essential part of rehabilitation and help ensure the best possible outcome for the client.
Choice C reason:
Clients are not fitted for their prosthesis at the time of surgery. Fitting for a prosthesis typically occurs after the residual limb has sufficiently healed, which can take several weeks. The fitting process involves careful measurement and customization to ensure the prosthesis will be comfortable and functional.
Choice D reason:
While a special dressing is applied postoperatively, its primary purpose is not to cushion the prosthesis. Initially, dressings are used to protect the surgical site, control swelling, and promote healing. The prosthesis is fitted after the residual limb has healed, and at that time, different types of socket liners may be used for cushioning.
Correct Answer is C
Explanation
Choice A reason:
While explaining discharge instructions is an important part of patient education and ensuring safety after leaving the hospital, it is not the immediate priority. The nurse must first address any potential medical issues that could compromise the patient's health, such as circulation and nerve function in the affected limb.
Choice B reason:
Applying an ice pack to the casted leg can help reduce swelling and provide comfort to the client. This is often recommended for the first 24 to 72 hours after the cast is applied, especially if the cast is on a leg. However, this is secondary to assessing the neurovascular status of the limb.
Choice C reason:
Performing a neurovascular assessment is the priority action for the nurse. This assessment includes checking for sensation, warmth, capillary refill, pulses, and movement. It is crucial to identify any signs of compromised blood flow or nerve injury early to prevent further complications.
Choice D reason:
Providing reassurance to the client and parents is important for emotional support and can help alleviate anxiety. However, the nurse's immediate priority is to ensure the physical well-being of the client, which includes performing a neurovascular assessment to detect any urgent issues.

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