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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not evident in this scenario where the pH is low and PaCO2 is elevated.
B. The low pH of 7.3 indicates acidemia, and the elevated PaCO2 of 50 mm Hg suggests respiratory acidosis, where the body is retaining carbon dioxide, leading to an increase in acidity.
C. Metabolic acidosis would present with a low pH and a normal or decreased PaCO2, which is not the case here since the PaCO2 is elevated.
D. Metabolic alkalosis would show a high pH and elevated HCO3 levels, which is not consistent with the given ABG results.
Correct Answer is B
Explanation
A. Fluid overload is not an allergic reaction but rather a complication of transfusion related to the volume of fluid administered, thus diphenhydramine would not be appropriate.
B. Urticaria, or hives, is a common mild allergic reaction that can occur during blood transfusions. Administering diphenhydramine can help prevent or treat this response.
C. Hemolysis is a serious reaction involving the destruction of red blood cells, often due to blood type incompatibility; it is not alleviated by antihistamines.
D. Fever can occur during transfusions but is typically due to non-specific immune reactions and does not respond to diphenhydramine.