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:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.
Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.
Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.
Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.
Correct Answer is B
Explanation
Choice A reason:
Urinary retention is not commonly reported as an adverse effect of tamoxifen. While urinary symptoms can occur, they are not as prevalent as other side effects such as hot flashes or mood changes.
Choice B reason:
Hot flashes are a well-documented adverse effect of tamoxifen. They occur due to the antiestrogenic effects of the medication, which can mimic menopausal symptoms, including hot flashes. Tamoxifen is a medication used to treat breast cancer and is known to cause several adverse effects. Based on the information provided by reliable health sources, hot flashes are a common side effect experienced by patients taking tamoxifen
Choice C reason:
Constipation is not typically listed as a common adverse effect of tamoxifen. Gastrointestinal symptoms may occur, but they are more often related to nausea or vomiting rather than constipation.
Choice D reason:
Tinnitus, or ringing in the ears, is not a recognized common adverse effect of tamoxifen. While patients may experience a range of side effects, tinnitus is not frequently associated with the use of tamoxifen.
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