Nokea
A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority nursing diagnosis for this client is:
- A. Anxiety
- B. Risk for self-mutilation
- C. Risk for other-directed violence
- D. Ineffective coping
Correct Answer: B
Rationale: The correct answer is B: Risk for self-mutilation. This is the priority nursing diagnosis because the client is displaying behaviors such as self-injury due to difficulty tolerating angry feelings. Self-mutilation poses an immediate risk to the client's safety and requires immediate intervention. The other choices are incorrect because anxiety (A) is a common symptom of borderline personality disorder but not the priority in this case. Risk for other-directed violence (C) is not indicated as the client is primarily harming themselves. Ineffective coping (D) is a broad diagnosis that does not address the immediate risk of self-mutilation.
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A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply.
- A. Allow the patient to talk at a comfortable pace.
- B. Place the patient in a private room with a caregiver.
- C. Pose questions in nonjudgmental, empathetic ways.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Allow the patient to talk at a comfortable pace. This intervention is appropriate because it promotes the patient's autonomy and empowerment in sharing their experience, which can be therapeutic. It also helps establish trust and rapport, facilitating effective communication and assessment.
Incorrect choices:
B: Placing the patient in a private room with a caregiver can be important for privacy and support but may not be the immediate priority.
C: Posing questions in nonjudgmental, empathetic ways is crucial but may not be as important as allowing the patient to talk at their own pace initially.
D: None of the above is incorrect as allowing the patient to talk is a crucial step in providing appropriate care for a patient who has experienced trauma.
Major concerns of the elderly living alone in their home are: (Name 1)
- A. Safety
- B. Quality of life
- C. Support system
- D. Access to medical care
Correct Answer: A
Rationale: Safety (A) is a major concern for the elderly living alone, as it impacts their ability to remain independent and healthy. Other concerns like quality of life (B), support system (C), and medical access (D) are also relevant but asked as a single choice here.
Which of the following should the nurse use as a basis for explaining the etiology of Alzheimer's disease to the family of a client with this disease?
- A. It is a secondary dementia indicated by loss of recent memory and disorientation to time and place.
- B. It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence of a beta-amyloid protein in the neurons resulting in senile plaques.
- C. It is a secondary dementia that is treatable with analysis of the diet and removal of toxic substances from the diet and environment.
- D. It is a primary dementia characterized by stepwise decreases in cognitive abilities. It is irreversible but treatable with antihypertensive medications.
Correct Answer: B
Rationale: The correct answer is B because Alzheimer's disease is a primary dementia that is characterized by the presence of beta-amyloid protein in neurons leading to the formation of senile plaques. This explanation is accurate as it describes the key pathological process underlying Alzheimer's disease.
Choice A is incorrect because Alzheimer's disease is a primary dementia, not a secondary dementia. Choice C is incorrect because the etiology of Alzheimer's disease is not related to diet or toxic substances, so it is not treatable in that way. Choice D is incorrect because while Alzheimer's disease is irreversible, it is not treatable with antihypertensive medications as these medications are not effective in managing the disease process of Alzheimer's.
Which behavior would the nurse expect to observe in a person who commits psychic rape?
- A. The perpetrator gives money to the patient after the rape.
- B. The perpetrator seduces the patient by providing wine, flowers, and music.
- C. The perpetrator threatens the patient to submit or else be severely beaten.
- D. The perpetrator mentions always including violent bondage in sexual activities.
Correct Answer: D
Rationale: The correct answer is D because mentioning violent bondage in sexual activities indicates a pattern of behavior associated with psychic rape, where the perpetrator exerts control and inflicts harm on the victim. This choice aligns with the power dynamics and manipulation typically seen in cases of psychic rape.
A: Giving money after the rape does not necessarily indicate psychic rape and is more characteristic of bribery or transactional behavior.
B: Seduction with wine, flowers, and music may indicate manipulation but does not specifically relate to the psychological violation inherent in psychic rape.
C: Threatening the patient with violence is a form of physical coercion rather than psychic rape, which involves psychological manipulation and violation.
A patient with mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Ineffective coping
- C. Ineffective management of therapeutic regime
- D. Imbalanced nutrition
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition. Priority is given to physiological needs. The patient not eating for 3 days can lead to serious health complications. This nursing diagnosis addresses the immediate risk to the patient's physical well-being. Choices A, B, and C are important but addressing the patient's nutritional needs is the priority to prevent further deterioration in their condition.