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brandon... brandon...
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6 years ago
A 32-year-old woman brought to the emergency department reports being sexually assaulted. The patient is confused about where she is and she has a large laceration above the right eye. Which action should the nurse take first?
 
  a. Assess the patient's neurologic status.
  b. Assist the patient to remove her clothing.
  c. Contact the sexual assault nurse examiner (SANE).
  d. Ask the patient to describe what occurred during the assault.

Question 2

A 48-year-old woman in the emergency department reports that she has been sexually assaulted. Which action by the nurse will be most important in maintaining the medicolegal chain of evidence?
 
  a. Labeling all specimens and other materials obtained from the patient.
  b. Assisting the patient in filling out the application for financial compensation.
  c. Discussing the availability of the morning-after pill for pregnancy prevention.
  d. Educating the patient about baseline sexually transmitted infection (STI) testing.

Question 3

An 18-year-old requests a prescription for birth control pills to control severe abdominal cramping and headaches during her menstrual periods. Which should the nurse take first?
 
  a. Determine whether the patient is sexually active.
  b. Teach about the side effects of oral contraceptives.
  c. Take a personal and family health history from the patient.
  d. Suggest nonsteroidal antiinflammatory drugs (NSAIDs) for relief.

Question 4

Which action should the nurse take when a 35-year-old patient has a result of minor cellular changes on her Pap test?
 
  a. Teach the patient about colposcopy.
  b. Teach the patient about punch biopsy.
  c. Schedule another Pap test in 4 months.
  d. Administer the human papillomavirus (HPV) vaccine.

Question 5

A 31-year-old patient has just been instructed in the treatment for a Chlamydia trachomatis vaginal infection. Which patient statement indicates that the nurse's teaching has been effective?
 
  a. I can purchase an over-the-counter medication to treat this infection.
  b. The symptoms are due to the overgrowth of normal vaginal bacteria.
  c. The medication will need to be inserted once daily with an applicator.
  d. Both my partner and I will need to take the medication for a full week.
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wrote...
6 years ago
The answer to question 1

ANS: A
The first priority is to treat urgent medical problems associated with the sexual assault. The patient's head injury may be associated with a head trauma such as a skull fracture or subdural hematoma. Therefore her neurologic status should be assessed first. The other nursing actions are also appropriate, but they are not as high in priority as assessment and treatment for acute physiologic injury.

The answer to question 2

ANS: A
The careful labeling of specimens and materials will assist in maintaining the chain of evidence. Assisting with paperwork, and discussing STIs and pregnancy prevention are interventions that might be appropriate after sexual assault, but they do not help maintain the legal chain of evidence.

The answer to question 3

ANS: C
Oral contraceptives may be appropriate to control this patient's symptoms, but the patient's health history may indicate contraindications to oral contraceptive use. Because the patient is requesting contraceptives for management of dysmenorrhea, whether she is sexually active is irrelevant. Because the patient is asking for birth control pills, responding that she should try NSAIDs is nontherapeutic. The patient does not need teaching about oral contraceptive side effects at this time.

The answer to question 4

ANS: C
Patients with minor changes on the Pap test can be followed with Pap tests every 4 to 6 months because these changes may revert to normal. Punch biopsy or colposcopy may be used if the Pap test shows more prominent changes. The HPV vaccine may reduce the risk for cervical cancer, but it is recommended only for ages 9 through 26.

The answer to question 5

ANS: D
Chlamydia is a sexually transmitted bacterial infection that requires treatment of both partners with antibiotics for 7 days. The other statements are true for the treatment of Candida albicans infection.
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