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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. Administering aspirin is incorrect because aspirin is ineffective in reducing core temperature in heat stroke and can increase the risk of bleeding.
B. Providing oral fluids is incorrect because the patient is confused and at risk for aspiration; IV fluids are preferred.
C. Applying a cooling blanket is correct because this patient is experiencing heat stroke, and rapid cooling is essential to prevent organ damage. Cooling blankets, ice packs, and immersion in cool water are key interventions.
D. Giving salt tablets is incorrect as rapid sodium replacement can cause fluid shifts and worsen the condition; IV fluids are preferred.

A. Protein and calcium B. Protein and sodium C. Fat and magnesium D. Carbohydrate and potassium

Correct Answer is B

Explanation

A. Protein may be restricted in cases of liver failure to prevent ammonia buildup, but calcium isn't typically restricted in liver failure.
B. In acute liver failure and encephalopathy, protein may be restricted to minimize ammonia production, and sodium may be restricted to manage fluid retention and prevent further complications.
C. Fat and magnesium are not typically restricted in this condition.
D. Carbohydrate and potassium are not primary dietary restrictions for acute liver failure.

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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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