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A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient's underclothes. Priority actions by the nurse should focus on:
- A. Preserving rape evidence.
- B. Maintaining the patient's airway.
- C. Obtaining a description of the rape.
- D. Determining what drugs were ingested.
Correct Answer: B
Rationale: The correct answer is B: Maintaining the patient's airway. This is the priority action because the patient is unconscious and airway patency is crucial for survival. Preserving rape evidence (A) can be important, but the patient's immediate health takes precedence. Obtaining a description of the rape (C) can wait until the patient's condition stabilizes. Determining what drugs were ingested (D) is important but secondary to ensuring the patient can breathe.
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The nurse is planning care for a battered woman who has mentioned, 'Someday I'll have to leave him.' Which outcome should the nurse include in the plan of care for this client?
- A. Client will leave husband for a safe environment within 3 weeks
- B. Client will state that she feels more relaxed after consultation with nurse
- C. Client will state that she feels strong enough to return to the situation
- D. Client will verbalize awareness of the dangerousness of her situation
Correct Answer: D
Rationale: The correct answer is D: Client will verbalize awareness of the dangerousness of her situation. This outcome is crucial as it indicates the client's understanding of the risks involved in her current situation. By verbalizing awareness, the client is acknowledging the potential harm and taking a significant step towards recognizing the need for change. This outcome lays the foundation for further interventions and support.
Choice A is incorrect because setting a specific timeline for leaving may not be feasible or safe for the client. Choice B is incorrect as feeling relaxed does not necessarily address the underlying issue of abuse. Choice C is incorrect as feeling strong does not necessarily equate to recognizing the dangers of the situation. The focus should be on increasing awareness and empowering the client to make informed decisions.
Multiple personality or dissociative identity disorder often begins
- A. as a result of combat exhaustion
- B. in adulthood as a response to unremitting phobias
- C. as a consequence of post-traumatic stress disorders
- D. in childhood as a result of unbearable experiences
Correct Answer: D
Rationale: Dissociative identity disorder typically originates in childhood from severe trauma, such as abuse, leading to identity fragmentation.
A patient referred to the eating disorders clinic lost 35 pounds over 3 months. To assess eating patterns, the nurse should ask:
- A. Do you often feel fat?
- B. Who plans the family meals?
- C. What do you eat in a typical day?
- D. What do you think about your present weight?
Correct Answer: C
Rationale: Rationale:
C is correct because it directly addresses the assessment of eating patterns by inquiring about the patient's actual food intake. This question provides valuable information on the quantity and quality of food consumed, aiding in diagnosing and treating eating disorders.
Other choices are incorrect:
A is focused on body image and self-perception, not eating patterns.
B is about family dynamics, not the patient's individual eating habits.
D pertains to body weight perception, not the specifics of the patient's diet.
Which of the following behaviors is most consistent with bulimia nervosa?
- A. Severe food restriction and extreme weight loss.
- B. Binge eating followed by vomiting or use of laxatives.
- C. Excessive exercise and rigid dietary rules.
- D. Overeating and no attempts to control food intake.
Correct Answer: B
Rationale: The correct answer is B: Binge eating followed by vomiting or use of laxatives. This behavior is most consistent with bulimia nervosa as it involves recurrent episodes of binge eating followed by compensatory behaviors like self-induced vomiting or laxative use. This pattern of behavior is a key diagnostic criteria for bulimia nervosa.
A: Severe food restriction and extreme weight loss is more indicative of anorexia nervosa, not bulimia nervosa.
C: Excessive exercise and rigid dietary rules may be seen in various eating disorders, but it is not specific to bulimia nervosa.
D: Overeating without attempts to control food intake is more characteristic of binge eating disorder, not bulimia nervosa.
Which of the following should be considered in the assessment of oppositional behaviours in children?
- A. Peer relationships
- B. Child s developmental stage
- C. Behaviours exhibited at home
- D. All of the above
Correct Answer: D
Rationale: All factorsâ€â€peer relationships, developmental stage, home behavior, and family historyâ€â€are critical in assessing oppositional behaviors comprehensively.