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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. A minor with acute pain is incorrect because while urgent, it does not pose an immediate life-threatening risk and would likely fall into the urgent category.
B. A postmenopausal woman with bruising is incorrect because bruising alone does not indicate an immediate life-threatening condition and would be categorized as non-urgent.
C. A sexually assaulted patient with multiple facial fractures is incorrect because while serious, it is not immediately life-threatening and would likely be categorized as urgent.
D. A rape victim with active hemorrhage in the abdomen is correct because uncontrolled bleeding is life-threatening and requires immediate intervention, placing this patient in the emergent category.

A. History of type 2 diabetes B. Interval and RR interval are irregular C. Shortened PR interval D. Inconsistently shaped P waves E. PR interval is constant. F. Apical heart rate G. Fewer QRS complexes than P waves H. PP interval is equal to RR interval.

Correct Answer is ["G"]

Explanation

A. History of type 2 diabetes is not a rhythm characteristic seen on an ECG. While diabetes can contribute to the development of cardiovascular issues, it does not specifically describe the characteristics of a third-degree AV block on an ECG.
B. Interval and RR interval are irregular is incorrect. In third-degree AV block (also known as complete heart block), the atrial rate and ventricular rate are typically regular, but the atrial and ventricular rhythms are completely dissociated.
C. Shortened PR interval is incorrect. In third-degree AV block, there is no consistent PR interval because the atria and ventricles are functioning independently.
D. Inconsistently shaped P waves is incorrect. P waves may appear normal, but the relationship between P waves and QRS complexes is lost in third-degree AV block.
E. PR interval is constant is incorrect. In third-degree AV block, the PR interval is inconsistent or absent, as the atrial and ventricular rates are independent of each other.
F. Apical heart rate is irrelevant here. The ECG will show the characteristic findings of third-degree AV block rather than focusing on apical heart rate alone.
G. Fewer QRS complexes than P waves is correct. In third-degree AV block, the atrial impulses (P waves) are conducted normally, but the ventricles are completely dissociated from the atrial rhythm, leading to fewer QRS complexes than P waves, as the ventricles may be paced by an escape rhythm.
H. PP interval is equal to RR interval is not necessarily true in third-degree AV block. The PP and RR intervals may be different depending on the escape rhythm, but they are not usually exactly equal.

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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.)

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Naxlex Comprehensive Predictor Exams

Which patient situation will be classified in the emergent triage category?

Correct Answer is D

Explanation

An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?

Correct Answer is ["G"]

Explanation

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