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 ["A","C"]
Explanation
A. Orthostatic hypotension is a common sign of hypovolemia, as the lack of fluid volume can lead to a drop in blood pressure when changing positions.
B. Bradycardia is not typically associated with fluid volume deficit; tachycardia is more common as the body tries to compensate for low blood volume.
C. Decreased skin turgor is a classic sign of dehydration and fluid volume deficit, indicating reduced skin elasticity.
D. Weight gain is associated with fluid volume overload, not deficit.
E. Pulmonary edema is related to fluid volume overload or congestive heart failure, not hypovolemia.
Correct Answer is C
Explanation
A. Decreased groin pain is not an indicator of therapeutic response specific to the effects of epinephrine in treating angioedema.
B. While tolerating a second dose of medication with minimal peripheral edema is positive, it does not directly reflect the immediate therapeutic effects of epinephrine.
C. Unlabored respirations indicate improved airway patency and reduced bronchoconstriction, which are key therapeutic outcomes of epinephrine administration in angioedema.
D. Blood pressure returning to premedication levels is beneficial but is not the most immediate indicator of epinephrine's therapeutic effect in managing angioedema.