A nurse is caring for a client who was sexually assaulted. An assessment of the client indicates that they might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?

Where did the assault occur?

Do you give us permission to call the police?

Who was the individual who assaulted you?

What day and time did the assault take place?

Answer and Explanation

The Correct Answer is C

A. While knowing the location of the assault may be relevant for police reports, it does not directly pertain to the client’s health and potential exposure to HIV.
B. Permission to contact the police is important for legal reasons, but the priority is to address the client's health needs first.
C. Identifying the individual who assaulted the client is critical for assessing the risk of HIV exposure and determining the need for post-exposure prophylaxis (PEP). This question directly impacts the client’s immediate health care.
D. Understanding the day and time of the assault is useful for legal documentation but is less critical than assessing potential exposure to HIV.

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Correct Answer is C

Explanation

A. Pneumocystis lung infection is an opportunistic infection that typically occurs in later stages of HIV/AIDS when the immune system is significantly weakened, not during the initial phase of infection.
B. Fungal and bacterial infections are also associated with advanced HIV/AIDS due to immunosuppression and not seen in the initial phase of infection.
C. Flu-like symptoms and night sweats are common initial symptoms of HIV infection, often occurring 2-4 weeks after exposure during the acute retroviral syndrome phase.
D. Kaposi's sarcoma is a cancer associated with advanced HIV/AIDS and does not manifest during the initial symptoms of infection.

A. IV antibiotics B. Urinalysis C. Chest x-ray D. Chest tube placement E. Admit to inpatient F. Airborne precautions G. Draw an STI lab panel H. Complete blood count

Correct Answer is ["A","C","E","H"]

Explanation

The nurse anticipates the following orders from the provider based on the suspected diagnosis:

A. IV antibiotics: To treat the suspected infection.
C. Chest x-ray: To assess the lungs for signs of infection, such as pneumonia.
E. Admit to inpatient: The client's worsening condition and need for aggressive treatment warrant hospitalization.
H. Complete blood count: To assess the client's overall health status and identify any abnormalities, such as anemia or infection.

Rationale:

B. Urinalysis: While a urinalysis can be helpful in assessing for urinary tract infections, it is not a priority in this case.
D. Chest tube placement: This is not indicated unless the client develops a pleural effusion or pneumothorax.
F. Airborne precautions: This is not necessary for the client's current condition.
G. Draw an STI lab panel: While this may be relevant for the client's overall health, it is not a priority at this time, especially given the client's acute presentation.

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A nurse is caring for a client who was sexually assaulted. An assessment of the client indicates that they might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?

Correct Answer is C

Explanation

A nurse is caring for a client in the clinic. Exhibits The nurse anticipates which of the following orders from the provider based on the suspected diagnosis? (Select all that apply)

Correct Answer is ["A","C","E","H"]

Explanation

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