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?

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

Choice A reason:
Instructing the client to eat cooked foods only is a necessary precaution for immunosuppressed individuals. Cooking foods thoroughly can help eliminate harmful bacteria and other pathogens that could cause infection in a person with a weakened immune system.

Choice B reason:
Restricting visitors who have active infections is crucial in preventing the transmission of potentially harmful pathogens to the immunosuppressed client. Even minor infections in healthy individuals can be severe for someone with a compromised immune system.

Choice C reason:
Disposing of all linen in the trash after use is not a standard precaution for immunosuppressed clients. Used linens should be handled according to the healthcare facility's infection control policies, which often include laundering and not simply discarding in the trash.

Choice D reason:
Limiting the client from bathing daily is not a necessary precaution for immunosuppression. Maintaining good personal hygiene is important, and there is no need to restrict regular bathing unless there is a specific contraindication.

Choice E reason:
Donning a mask, gloves, and gown when caring for an immunosuppressed client can be part of standard precautions, especially if the client is in a protective environment or if the nurse is performing a procedure that has a high risk of contact with bodily fluids or if the client has a known infection.

A. Ecchymosis of the surrounding skin B. Acute pain C. Bounding distal pulse D. Increasing edema

Correct Answer is D

Explanation

Choice A reason:
Ecchymosis, or bruising, of the surrounding skin is a common finding associated with fractures due to the trauma to blood vessels in the area. While it can indicate bleeding or injury, ecchymosis itself does not specifically indicate impaired venous return.

Choice B reason:
Acute pain is a typical symptom following a fracture and results from the injury to the bone and surrounding tissues. Pain is an expected finding and does not directly suggest an issue with venous return.

Choice C reason:
A bounding distal pulse may actually suggest increased arterial flow or could be a sign of other conditions such as high blood pressure or fever. It does not indicate impaired venous return, which is typically characterized by a lack of pulse or a very weak pulse.

Choice D reason:
Increasing edema, or swelling, in the affected arm is a sign of impaired venous return. When veins are unable to effectively return blood to the heart, fluid can accumulate in the tissues, leading to edema. In the context of a fracture, this could be due to compression or damage to the veins, which can impede blood flow and result in swelling.

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Which of the following questions is most important to ask a client who might have been exposed to HIV after being sexually assaulted?

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Naxlex Comprehensive Predictor Exams

A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Correct Answer is D

Explanation

A group of nurses are discussing risk factors for the transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?

A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?

A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

A nurse is assessing a client who has a spinal cord injury with heterotopic ossifications. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?

A nurse is providing teaching about dietary supplements to a client who has erectile dysfunction and has been prescribed nitroglycerin. Which of the following statements is the most important for the nurse to include in the teaching?