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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 ["A","C","D"]

Explanation

A. Support system: Spiritual beliefs often provide a supportive community and network of individuals that can help a person navigate illness and difficult situations. A strong support system can positively influence a person's health and well-being.
B. Knowledge that illness is a punishment: This belief is typically negative and may lead to feelings of guilt or despair, which can have a detrimental effect on health. It does not support overall well-being.
C. Endurance of extreme stress: Spiritual beliefs can provide a sense of purpose and strength that helps individuals cope with stress and adversity, promoting resilience in the face of challenges.
D. Positive emotions: Spirituality can foster hope, gratitude, and a sense of peace, all of which can enhance emotional well-being and improve overall health outcomes.
E. Diet: While some spiritual beliefs may have dietary guidelines, not all spiritual practices directly influence diet in a way that enhances health. It is more common for spirituality to affect emotional and mental well-being.

A. Remove tight clothing. B. Administer acetaminophen. C. Give salt tablets. D. Place in cool water. E. Initiate intravenous (IV) fluids.

Correct Answer is ["A","D","E"]

Explanation

A. Removing tight clothing is correct because it allows for better heat dissipation and helps cool the patient.
B. Administering acetaminophen is incorrect as acetaminophen reduces fever from infection, not from heat stroke, which requires active cooling measures.
C. Giving salt tablets is incorrect as rapid sodium replacement can cause dangerous fluid shifts; IV fluids are preferred for controlled electrolyte correction.
D. Placing in cool water is correct because immersion cooling is one of the most effective methods to lower body temperature in heat stroke.
E. Initiating IV fluids is correct as the patient likely has dehydration and electrolyte imbalances, requiring fluid resuscitation with isotonic fluids.

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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

Naxlex Comprehensive Predictor Exams

A nurse is paying particular attention to the spiritual needs of a client today. The nurse identifies that spiritual beliefs can have a positive effect on general health of a client in which ways? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Which action would the nurse take if the patient brought to the emergency after hiking in the desert for 2 hours is confused, reports hallucinations, and has a temperature of 104.2°F (40.1°C), dark amber urine, and a serum sodium of 128 mEq/L? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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