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
Explanation
A. Oliguria, or decreased urine output, is a common finding in hypovolemia due to reduced renal perfusion and decreased blood flow to the kidneys.
B. Hypertension is unlikely in hypovolemia; instead, clients typically exhibit hypotension due to decreased circulating blood volume.
C. Bradycardia is not a typical finding in hypovolemia; instead, tachycardia is more commonly observed as the body compensates for reduced blood volume.
D. Peripheral edema is associated with fluid overload rather than hypovolemia, as a decrease in blood volume usually leads to less fluid accumulation in the tissues.
Correct Answer is C
Explanation
A. DIC is characterized by a low platelet count due to the consumption of platelets in the coagulation process, not an elevated count.
B. While heparin may be used in the management of DIC in some cases, it is not a lifelong treatment nor a cure for the condition, as DIC results from an underlying condition rather than being a standalone disease.
C. DIC involves the overactivation of the coagulation cascade, leading to the formation of fibrin clots and subsequent consumption of clotting factors and platelets, thus making this statement accurate.
D. DIC is not a genetic disorder but rather a complication often associated with severe infections, trauma, or other conditions, and it is not primarily due to vitamin K deficiency.