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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Correct Answer is D
Explanation
A. Furosemide is a diuretic and is not indicated in the acute management of anaphylaxis.
B. Methylprednisolone is a corticosteroid that may be used later to reduce inflammation but is not the first-line treatment in anaphylaxis.
C. Dobutamine is a medication used to treat heart failure and shock but does not address the acute allergic reaction.
D. Epinephrine is the first-line treatment for anaphylactic shock, as it acts quickly to reverse severe allergic reactions by causing vasoconstriction, bronchodilation, and inhibiting further release of mediators from mast cells.
Correct Answer is B
Explanation
A. Increased systemic vascular resistance is typically associated with hypovolemic or cardiogenic shock, not distributive shock.
B. Distributive shock is characterized by systemic vasodilation, which leads to a decrease in systemic vascular resistance and results in inadequate tissue perfusion despite normal or increased cardiac output.
C. Loss of myocardial contractility is related to cardiogenic shock, not distributive shock.
D. Loss of blood volume is a characteristic of hypovolemic shock, whereas distributive shock occurs even when blood volume is normal due to vasodilation.