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A patient in the long-term phase of the rape-trauma syndrome had intrusive thoughts of the attack and developed fears of being alone. Which finding best demonstrates the patient has improved? The patient!
- A. Uses increased activity to reduce fear.
- B. Plans coping strategies for fearful situations.
- C. Temporarily withdraws from social situations.
- D. Expresses willingness to engage in sexual activity.
Correct Answer: B
Rationale: The correct answer is B because planning coping strategies for fearful situations indicates the patient is actively working on managing their fears and trauma, showing progress and improvement. Choice A is incorrect as increased activity may be a maladaptive coping mechanism. Choice C suggests social withdrawal, which is a sign of regression. Choice D may indicate premature attempts to engage in sexual activity without addressing the underlying trauma. Overall, choice B demonstrates proactive steps towards healing and recovery.
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In addition to antidepressants, which of the following is usual treatment for postpartum depression?
- A. Antipsychotics
- B. Psychotherapy
- C. Hormone replacement
- D. Temporary removal of the baby from the home
Correct Answer: B
Rationale: Psychotherapy (B) along with antidepressants are the major treatments for postpartum depression. Patients usually are not psychotic (A), hormone replacement (C) is not indicated, and mother and baby should be kept together with support (D).
A delusion is defined as seeing something that is not real
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: A delusion is a fixed false belief, not a perception (hallucination involves seeing/hearing something not real).
In most anxiety disorders, the person's distress is
- A. focused on a specific situation
- B. related to ordinary life stresses
- C. greatly out of proportion to the situation
- D. based on a physical cause
Correct Answer: C
Rationale: Anxiety disorders feature exaggerated distress disproportionate to the trigger, unlike normal stress.
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The nurse at the day care center noticed the patient was unkempt and had multiple bruises. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes I just cannot bear to care for her."Â Which nursing diagnosis would be most important to address for this patient?
- A. Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision
- B. Nonadherence related to confusion and disorientation, as evidenced by lack of cooperation
- C. Anxiety related to increasing disorientation, as evidenced by the patient wandering at night
- D. Impaired verbal communication related to brain impairment, as evidenced by the patient's confusion
Correct Answer: A
Rationale: The correct answer is A: Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision. The rationale is that the patient's Alzheimer's disease has led to impaired cognitive function, making her at risk for injury due to wandering and falls. The daughter's lack of supervision and inability to manage the patient's needs further exacerbate this risk. Choices B, C, and D are incorrect because they do not directly address the immediate safety concern of the patient being at risk for injury. Nonadherence, anxiety, and impaired communication are important issues but do not take precedence over the patient's safety in this context.
What is the most appropriate goal for a nurse caring for a patient with anorexia nervosa?
- A. The patient will gain weight rapidly to achieve a normal weight.
- B. The patient will stabilize their weight and maintain adequate nutrition.
- C. The patient will achieve full recovery without needing additional support.
- D. The patient will accept their body image as normal and healthy.
Correct Answer: B
Rationale: The most appropriate goal for a nurse caring for a patient with anorexia nervosa is for the patient to stabilize their weight and maintain adequate nutrition (Choice B). This goal is crucial because rapid weight gain can have negative physical and psychological consequences for the patient. Stabilizing weight helps prevent complications like refeeding syndrome and supports the patient's overall health. It also addresses the immediate nutritional needs of the patient. Choices A, C, and D are incorrect because rapid weight gain can be harmful, full recovery often requires ongoing support, and body image acceptance may not be the most pressing concern for someone with anorexia nervosa.