On a recent exam, one question (which was supposedly an NCLEX question) was answered incorrectly by 28 out of 30 students in our class, yet our professor remains adamant. Here it is:
"A man who has a profuse, purulent urethral discharge with painful urination is seen at the sexually transmitted disease (STD) clinic. Which information will be most important for the nurse to obtain?"
A.) The date of his last sexual activity
B.) A prior history of STDs
C.) When the symptoms began
D.) The names of recent sexual partner
The class majority was an even split between B and C. Apparently the right answer was D. This was rationalized as a community health choice; a prioritization of preventing the spread of this STD and protecting the health of his partners. It's not that the other actions won't be performed, just that this one is the *most important.*
Funnily, this was the first answer I crossed off, for sounding absurdley wrong. To me, this seems to be a dark ethical decision to place "the good of the many" above his, at least initially. I can't wrap my mind around focusing on everyone else while this man is my patient. Note, this question doesn't state I'm a community health nurse, or someone else who may place a much greater emphasis on the epidemiological aspects of his visit.
I'm very curious to hear some opinions on this! Thanks
I would think that the first priority would be to treat the patient's symptoms, so I would answer "when did the symptoms begin". Past history is important, but not as relevant as current symptoms. When the symptoms began would provide information that might affect treatment. For example, a more established infection might require a longer course or different type of antibiotics, or if it's a female, she may imaging studies done to determine if there was any damage to her uterus.
I didn't know that clinics are required to collect the names of the partners and contact them. I thought that the patient was told to contact his previous partners and inform them. But I took a quick glance at a department of health website and that does appear to be the case. So I guess D is correct, but I would have crossed that off immediately too. I'd think that asking the names of someone's partners would scare a lot of people off and maybe even cause them to delay or try to treat the illness themselves. What if someone was secretly gay? What if someone was cheating on their spouse? What if someone had sex with someone they don't even know? What if they refuse to give up names?
I'm not arguing about the answer to the question, but I don't think it's a great practice. The patient should be encouraged to contact previous partners. Maybe he could even sign an "agreement" to notify them. And if he preferred, he could have the option of letting the health department contact the people. But requiring people to give up names... I don't know, it just doesn't seem right to me. I think it would prevent people from seeking care (so they try to treat the infection themselves, using someone's leftover antibiotics, meanwhile they are growing some kind of superinfection and likely continuing to spread the disease).
So how does all this fit in with anonymous HIV testing?
If I was taking the test, the answer I would have chosen was the ask about the onset of the symptoms one. To me, out of those choices, that answer would be the most important thing to find out when planning how to care for the patient. I see how that rationale is wrong, and I am glad I read this thread because I am sure something like that will come up in my classes!
I do have a question though. Part of the teacher's rationale had to do with the fact that the patient was being seen in a community health setting. Does the community health thing have a lot to do with the answer, and would the answer have been different if the patient first noticed his symptoms when he was in a hospital? Or would this still be the priority no matter what the setting was?
I'm not arguing about the answer to the question, but I don't think it's a great practice. The patient should be encouraged to contact previous partners. Maybe he could even sign an "agreement" to notify them. And if he preferred, he could have the option of letting the health department contact the people. But requiring people to give up names... I don't know, it just doesn't seem right to me. I think it would prevent people from seeking care (so they try to treat the infection themselves, using someone's leftover antibiotics, meanwhile they are growing some kind of superinfection and likely continuing to spread the disease).So how does all this fit in with anonymous HIV testing?
I do not think it's a great question because it doesn't reflect on how it actually happens in the real world. The practice is that the healthcare practioner is responsible for reporting the disease. It's up to the health dept as to what they do with that information. It's not illegal yet for a person w/ a sexually communicable disease to not tell their partners. I know it's been tossed around that HIV+ should tell they partners or face criminal charges but I don't believe that's happened yet. It's completly unethical though. The question is more about thinking beyond the scope of one patient, and what is the right and best thing to do. A nurse in such a situation should encourage the pt to tell anyone they've had sexual contact with about the disease, and report it to the health dept w/ all the necessary info they require. It's a bad question because it's something that is regulated on the county level so it doesn't make for a very clear question.Anonymous HIV testing is done by assigning pt's number and using that number to perform the test. The health dept is told that there is another positive test but not who it is. Really, it all comes down to what is the right thing to do beyond providing the patient care. It's a given that you're going to care for them. Now, what else are you going to do?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I would think that the first priority would be to treat the patient's symptoms, so I would answer "when did the symptoms begin". Past history is important, but not as relevant as current symptoms. When the symptoms began would provide information that might affect treatment. For example, a more established infection might require a longer course or different type of antibiotics, or if it's a female, she may imaging studies done to determine if there was any damage to her uterus.
I didn't know that clinics are required to collect the names of the partners and contact them. I thought that the patient was told to contact his previous partners and inform them. But I took a quick glance at a department of health website and that does appear to be the case. So I guess D is correct, but I would have crossed that off immediately too. I'd think that asking the names of someone's partners would scare a lot of people off and maybe even cause them to delay or try to treat the illness themselves. What if someone was secretly gay? What if someone was cheating on their spouse? What if someone had sex with someone they don't even know? What if they refuse to give up names?
I'm not arguing about the answer to the question, but I don't think it's a great practice. The patient should be encouraged to contact previous partners. Maybe he could even sign an "agreement" to notify them. And if he preferred, he could have the option of letting the health department contact the people. But requiring people to give up names... I don't know, it just doesn't seem right to me. I think it would prevent people from seeking care (so they try to treat the infection themselves, using someone's leftover antibiotics, meanwhile they are growing some kind of superinfection and likely continuing to spread the disease).
So how does all this fit in with anonymous HIV testing?
Here is my point. The question was what would be the most important over all not the first priority.
Here is my point. The question was what would be the most important over all not the first priority.
I think the most important thing would be to treat the patient that is there, not concern yourself with other unknown people who only have the potential of having a disease. Why would obtaining a list of a patient's sexual partners be more important than properly assessing his current condition? Furthermore, asking him how long he has had the symptoms could give the nurse a starting point for asking about the sexual partners. If he's had the symptoms a month, then the nurse would need to ask the names of all partners in the last 6 weeks. If he's only had the symptoms for 1 day, then she would only need to know about the past 2 to 3 weeks. Or maybe the answer would be "I've been having these symptoms since I had my member pierced last weekend. I've never had sex." I'm glad this wasn't a question on one of my exams, I'd be pretty annoyed with it too.
If it were clear in this question that the patient had HIV/AIDS, I'd have gone with the "correct" answer. However, it's not clear what he's got at this point, though those symptoms don't scream life threatening. I know they often occur together, but we are ALL taught not to assume on questions.
This is a crappy question. I'd have answered the way you did.
HIV/AIDS is not the only reportable infection. Another rule of NCLEX is that you usually have to assume information that is not clearly stated, but is alluded to.
Example: A patient with pneumonia is complaining of shortness of breath and difficulty breathing. Pulse oximetry is 84%. What should be the nurse's next action?
1. Ask what the patient as doing before the shortness of breath began
2. Obtain full set of vital signs
3. Apply supplemental oxygen
4. Contact the physician
Now, notice that the question does not state that the nurse has an order to apply oxygen. However, since applying oxygen is an option, NCLEX want you to assume that you do have an answer. You might think you need to call the physician to get an order for oxygen, but that is incorrect.
So no, this question doesn't state that the patient has an STD. However, he is at an STD clinic (generally not the first place people go with a medical problem) presenting with symptoms of an STD. It's very reasonable to then make the leap to the fact that the patient does have an STD.
I'm not arguing about the answer to the question, but I don't think it's a great practice. The patient should be encouraged to contact previous partners. Maybe he could even sign an "agreement" to notify them. And if he preferred, he could have the option of letting the health department contact the people. But requiring people to give up names... I don't know, it just doesn't seem right to me. I think it would prevent people from seeking care (so they try to treat the infection themselves, using someone's leftover antibiotics, meanwhile they are growing some kind of superinfection and likely continuing to spread the disease).
So how does all this fit in with anonymous HIV testing?
One big point that you're missing- People who are notified of their potential exposure to an STD are not told who exposed them. It's obvious, sometimes, in a monogamous relationship, but it's not disclosed.
There's a big problem with asking people to notify their own partners. What are you more likely to do:
1. Tell a nurse in the health department who you slept with, so partners can be notified that they need to be tested, but knowing that they will not be told that you specifically exposed them.
2. Find these people and tell them yourself that you have chlamydia and could have given it to them.
I'm inclined to believe that most people would choose option one and stay anonymous, rather then face the embarrassment of confronting people in person. Signing an agreement means nothing unless there is something legally binding.
Of course, no one is forced give the names of their partners. If they refuse, we aren't going to hog tie them and toss them in jail until they tell. They are treated as any other patient. However, most people are generally kind and honest. They don't want their partners to be living with a condition that could cause major medical problems, and would prefer they are notified.
Anonymous HIV testing is similar. However, people that test positive are not left high and dry without an option. They are educated about who to contact regarding their diagnosis in order to get treatment. Most will choose treatment, and yes, they will be asked about their sexual partners as well. However, treatment is a choice also. Nothing forces those who test positive to go to the doctor.
the higher-order questions are not poorly-vetted or arbitrary or mean-spirited. if they confuse you, then it's not because they are at fault. they are an indication of the very real milieu in which you will find yourselves as nurses, expected to perform at a higher standard than a lay person with a little advanced knowledge. they seek to identify who can and who can't.this final last-semester learning objective has sneaked up on you, but you ignore it at your peril. [color=#333333]
just curious- if the op is saying that 28/30 students answered the question incorrectly, and you're saying that answering questions such as this incorrectly means the student is not prepared for nursing, then are you suggesting that this class as a whole is past of the group "who can't"? i don't think she is "ignoring it at [her] peril" - she is here asking and trying to understand the rationale.
i don't say she is ignoring it (and good for her for asking some people who can answer it better than her faculty, i guess), but i'm saying that sometimes nursing students do ignore it. i believe that 28 of those 30 did not think of the higher implications of the question because they didn't stop to think that there could be something bigger going on. they fixated on the details and failed to see the big picture. this may be where they get caught short, where they have their collective "aha!" moment. i do hope so. and i am pretty sure there will be a mass movement to have this question thrown out of the exam because, like, it's so not fair to count it because so many of us got it wrong so it must be a bad question! (raise your hands if you can name this tune in three notes.)
the ana scope and standards of practice (a slim volume available at your favorite onlinebookseller, and which i commend to your attention) is very clear on the fact the the patient to be the subject of your responsibility, assessment, and care is the individual, family, group, or community. in this case, the students forgot that "community" part.
it may be a wake-up call to the faculty to explain not just this one question, but the greater question of how the nurse needs to think. we take facts and decide what they mean as a group; decide which ones, though true, aren't as important; discern the true path to take; and implement a nursing plan of care based on that discernment. it is a hard point to get across, i'll grant you.
but it is what we do, and you have to learn it to be a nurse.
I think the most important thing would be to treat the patient that is there, not concern yourself with other unknown people who only have the potential of having a disease. Why would obtaining a list of a patient's sexual partners be more important than properly assessing his current condition? Furthermore, asking him how long he has had the symptoms could give the nurse a starting point for asking about the sexual partners. If he's had the symptoms a month, then the nurse would need to ask the names of all partners in the last 6 weeks. If he's only had the symptoms for 1 day, then she would only need to know about the past 2 to 3 weeks. Or maybe the answer would be "I've been having these symptoms since I had my member pierced last weekend. I've never had sex." I'm glad this wasn't a question on one of my exams, I'd be pretty annoyed with it too.
Obtaining a list of sexual partners is more important because you could potentially have dozens of people infected with a contagious disease who are unknowingly infecting others. Women could be becoming infertile from PID as we speak because of an asymptomatic chlamydial infection. The question your asking is "Is the health of the general public more important then the health of one person. Ethically, they are of equivalent importance. Quantitatively, the general public is of much greater importance.
Bearing in mind what we know about STD's, no how long he has had the symptoms does not affect treatment. You can have certain STD's for months without having any symptoms. Chlamydia is so dangerous to women because in most cases there are no symptoms until it progresses to a pelvic infection which could cause permanent damage. It could be two weeks or eight months after initial exposure that the woman develops symptoms. So this patient might have just started exhibiting symptoms, but it does not definitively tell the nurse when he was infected. Initial symptoms of Syphillis, for example, may appear 10 days after infection, or 3 months after infection.
Again, don't forget that the patient is at an STD clinic. It's not the first place you think to go if you have weird symptoms but you've never had sex. It's reasonable to assume that the patient has an STD, since he is at an STD clinic and has related symptoms.
what i think the experienced nurses are saying is that it was a simple question with an obvious answer. it is likely an std, the correct answer is the same, whether or not the patient had hiv/aids.
i actually don't think this is a simple question. as grntea was saying, this is a higher-order question. there are several question formats on the progressively difficult question ladder. (please don't ask me to remember them all).
it begins with rote knowledge. such as: what are the symptoms of a blood clot? what's the definition of pneumonia?
eventually you get to assessment questions: your patient presents with x,y,z. what condition is most likely?
and critical thinking: a post-op patient becomes tachycardic with a fever of 101 and low bp. what would you expect the physician to order?
finally you reach the highest level of questions- application. application asks you to analyze all the data in the question, assess and draw conclusions, and choose your best response. this is certainly an application question, and a difficult one, but not impossible to figure out.
Clovery
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I would think that the first priority would be to treat the patient's symptoms, so I would answer "when did the symptoms begin". Past history is important, but not as relevant as current symptoms. When the symptoms began would provide information that might affect treatment. For example, a more established infection might require a longer course or different type of antibiotics, or if it's a female, she may imaging studies done to determine if there was any damage to her uterus.
I didn't know that clinics are required to collect the names of the partners and contact them. I thought that the patient was told to contact his previous partners and inform them. But I took a quick glance at a department of health website and that does appear to be the case. So I guess D is correct, but I would have crossed that off immediately too. I'd think that asking the names of someone's partners would scare a lot of people off and maybe even cause them to delay or try to treat the illness themselves. What if someone was secretly gay? What if someone was cheating on their spouse? What if someone had sex with someone they don't even know? What if they refuse to give up names?
I'm not arguing about the answer to the question, but I don't think it's a great practice. The patient should be encouraged to contact previous partners. Maybe he could even sign an "agreement" to notify them. And if he preferred, he could have the option of letting the health department contact the people. But requiring people to give up names... I don't know, it just doesn't seem right to me. I think it would prevent people from seeking care (so they try to treat the infection themselves, using someone's leftover antibiotics, meanwhile they are growing some kind of superinfection and likely continuing to spread the disease).
So how does all this fit in with anonymous HIV testing?