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.
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View Related questions
Correct Answer is A
Explanation
A. Respiratory acidosis is characterized by a low pH (7.32) and an elevated PaCO2 (48 mm Hg), indicating that the body is unable to eliminate CO2 effectively, leading to acid retention. The HCO3 level is within normal limits, suggesting that there is not a metabolic compensation occurring yet.
B. Metabolic alkalosis would present with a high pH and elevated bicarbonate levels, which is not the case here.
C. Respiratory alkalosis typically shows a high pH and low PaCO2, indicating hyperventilation, which does not align with the current findings.
D. Metabolic acidosis would show a low pH with a low HCO3, which is not supported by the HCO3 level of 23 mEq/L in this case.
Correct Answer is C
Explanation
A. Obstructive shock occurs when blood flow is physically obstructed, such as in cases of pulmonary embolism or cardiac tamponade, which is not indicated here as the cause is blood loss.
B. Septic shock is related to infection and systemic inflammatory response, not directly caused by blood loss.
C. Hypovolemic shock is caused by a significant loss of blood volume, leading to decreased blood pressure, which directly relates to the client losing 800 mL of blood during surgery. This condition results in inadequate perfusion and oxygen delivery to tissues.
D. Neurogenic shock results from spinal cord injuries leading to vasodilation and bradycardia, which is not applicable to this scenario.