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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 C

Explanation

A. Opioid agonists and opioid antagonists are incorrect because opioid antagonists (e.g., naloxone) reverse opioid effects rather than enhance pain relief.
B. Adjuvants and partial agonists are incorrect because while adjuvants can be helpful, partial agonists may not provide adequate pain relief for severe musculoskeletal pain.
C. NSAIDs and opioids are correct as NSAIDs reduce inflammation and opioids provide stronger analgesia when needed for severe pain.
D. NSAIDs and antidepressants are incorrect because while some antidepressants help with chronic neuropathic pain, they are not the primary treatment for musculoskeletal and soft tissue inflammation.

A. Placing the patient in prone position to improve draining from mouth B. Checking to make sure the tracheostomy cuff is inflated during tube feedings C. Placing the patient in the right lateral decubitus position to promote gastric emptying D. Discussing the use of metoclopramide to facilitate gastric motility with the practitioner

Correct Answer is B

Explanation

A. The prone position is not recommended for managing tube feeding regurgitation, as it could lead to aspiration into the lungs.
B. The first priority is to ensure that the tracheostomy cuff is inflated during tube feedings to prevent aspiration and to ensure that the feeding is directed into the stomach and not into the airway.
C. The lateral decubitus position can help with gastric emptying, but the priority is to ensure proper cuff inflation to prevent aspiration.
D. While metoclopramide may help with gastric motility, the immediate concern is managing the risk of aspiration, which requires confirming cuff inflation.

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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

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Correct Answer is B

Explanation

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