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A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

Ensure that the police are present when the examination is performed.

Assess and document any bruises and lacerations.

Have the patient shower or wash the perineal area before the examination.

Record a history of the event, using the patient's own words.

Answer and Explanation

Correct Answer : A,C,E

A. Labeling all torn or bloody clothes and placing each item in a separate brown bag is correct as it helps preserve forensic evidence.
B. Ensuring that the police are present during the examination is incorrect because the patient has the right to refuse police presence, and privacy should be maintained.
C. Assessing and documenting any bruises and lacerations is correct to provide an accurate record for legal and medical purposes.
D. Having the patient shower or wash the perineal area before the examination is incorrect because it can destroy crucial forensic evidence.
E. Recording a history of the event using the patient’s own words is correct as it ensures accurate documentation without interpretation or bias.

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Correct Answer is D

Explanation

A. Elevated ST segment is typically seen with conditions like pericarditis or acute myocardial injury, not hypokalemia.
B. Wide QRS could be related to various conditions, including bundle branch block or electrolyte disturbances, but it is not specifically indicative of hypokalemia.
C. Inverted P wave could be due to atrial arrhythmias but is not a hallmark of hypokalemia.
D. Abnormally prominent U wave is a classic sign of hypokalemia and is often seen following the T wave on an EKG.

A. It provides a way to interpret physiologic indicators. B. It eliminates the subjective component from the assessment. C. It provides consistency of assessment and management. D. It focuses on the objective component of the assessment.

Correct Answer is C

Explanation

A. Physiologic indicators can be helpful in pain assessment, but they are not directly linked to pain intensity scales, which are focused on subjective reports.
B. Pain intensity scales still involve a subjective component, as they rely on the patient’s report of their pain, even if the scale itself is structured.
C. A specific pain intensity scale provides consistency in how pain is assessed, allowing for more reliable tracking and management of pain across different shifts and caregivers.
D. While pain scales include subjective reports, they do not focus solely on objective data. The goal is to measure the patient's perception of pain.

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A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Nursing Test Bank

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