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A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to him.' The nurse is aware that the final decision to leave a batterer:
- A. Is complex and may take time.
- B. Should be made immediately.
- C. Is the responsibility of the nurse.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Is complex and may take time. The nurse understands that leaving an abusive relationship is a complex process that may take time. The client's statement of awareness indicates progress, but making the final decision to leave a batterer involves various factors such as safety planning, emotional readiness, and support systems. Choice B is incorrect as immediate decision-making can be dangerous without proper planning. Choice C is incorrect as the nurse's role is to support and empower the client but not make decisions for them. Choice D is incorrect as leaving an abuser is a personal decision that requires careful consideration.
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Which of the following procedures can be used to identify Down Syndrome pre-natally?
- A. Amniocentesis
- B. Amnioprolaxis
- C. Amniophalaxi
- D. Amniocalesis
Correct Answer: A
Rationale: Amniocentesis: A procedure extracting and analyzing amniotic fluid to identify Down Syndrome pre-natally in high-risk parents.
A victim of spousal abuse comes to the emergency department for treatment of a broken arm. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies any further suicidal thoughts. The nurse should document in the medical record that: (Select all that apply.)
- A. Signs of high anxiety and chronic stress are present.
- B. The patient relies on the perpetrator for basic needs.
- C. The patient has a history of suicidal ideation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Signs of high anxiety and chronic stress are present.
Rationale:
1. The patient displaying hypervigilance, anxiety, sleep disturbances, and dark circles under her eyes are indicators of high anxiety and chronic stress, common in victims of abuse.
2. Mentioning abuse occurring when the husband drinks, his jealousy, and control further support the presence of chronic stress and anxiety.
3. The patient's fleeting suicidal thoughts are a response to the abusive situation, not indicative of a history of suicidal ideation.
Summary:
B: The patient relying on the perpetrator for basic needs is not supported by the information provided.
C: There is no indication of a history of suicidal ideation, as the patient's thoughts are tied to her children and escaping the abusive relationship.
A patient has acute anxiety related to an automobile accident 2 hours ago. The patient needs teaching about drugs from which group?
- A. Tricyclic antidepressants
- B. Antipsychotic drugs
- C. Antimanic drugs
- D. Benzodiazepines
Correct Answer: D
Rationale: The correct answer is D: Benzodiazepines. Benzodiazepines are commonly used in the treatment of acute anxiety due to their rapid onset of action and effectiveness in managing symptoms such as panic attacks. They work by enhancing the inhibitory neurotransmitter GABA, leading to sedative and anxiolytic effects. Tricyclic antidepressants (Choice A) are not the first-line treatment for acute anxiety. Antipsychotic drugs (Choice B) are primarily used for conditions such as schizophrenia and bipolar disorder, not acute anxiety. Antimanic drugs (Choice C) are used to manage symptoms of mania in conditions like bipolar disorder, not acute anxiety. Therefore, the correct choice is Benzodiazepines due to their rapid efficacy and established role in managing acute anxiety.
A high school cheerleader was admitted to the eating disorders unit, having developed hypokalemia as the result of purging. Which of these medications will probably be prescribed for the client?
- A. Potassium.
- B. Calcium gluconate.
- C. Metoclopramide (Reglan).
- D. Ferrous sulfate.
Correct Answer: A
Rationale: Step 1: The client has hypokalemia, indicating low potassium levels due to purging.
Step 2: Potassium is essential for muscle function, including the heart.
Step 3: Correct Answer: A - Potassium will be prescribed to replenish the deficient levels.
Summary: B is incorrect as calcium gluconate is not used to treat hypokalemia. C and D are unrelated to treating low potassium levels.
Which of the following is a critical aspect of nursing care for patients with anorexia nervosa?
- A. Encouraging weight loss to avoid complications from obesity.
- B. Promoting normalization of eating habits and nutritional rehabilitation.
- C. Restricting fluid intake to reduce risk of water retention.
- D. Avoiding any pressure for the patient to gain weight rapidly.
Correct Answer: B
Rationale: The correct answer is B: Promoting normalization of eating habits and nutritional rehabilitation. This is critical in anorexia nervosa treatment to address malnutrition and restore a healthy relationship with food. Encouraging weight loss (A) is inappropriate as these patients are already underweight. Restricting fluid intake (C) can worsen dehydration and electrolyte imbalances. Avoiding pressure for rapid weight gain (D) is important, but the primary focus should be on promoting healthy eating habits and gradual weight restoration. By focusing on normalization of eating habits and nutritional rehabilitation, nurses can help patients with anorexia nervosa recover physically and mentally.