Nokea
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification?
- A. "I have heard that abusers try to keep their partner isolated from others."
- B. "I know that abusers lack social supports and social skills."
- C. "I know that men who are abusers gain power through intimidation."
- D. "I have heard that abusers think of themselves as important and have high self-esteem."
Correct Answer: D
Rationale: Answer D indicates a need for clarification because it presents a misconception about abusers. Abusers typically have low self-esteem and use power and control to compensate. This statement falsely suggests that abusers have high self-esteem and view themselves as important. This misunderstanding could lead to overlooking warning signs and risks associated with domestic violence. It's crucial for healthcare professionals to recognize the true dynamics of abusive relationships to provide appropriate support and interventions. Other choices (A, B, C) align with common knowledge about domestic violence, highlighting the tactics and behaviors typically associated with abusers.
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A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?
- A. "Why would you want to put your partner's health at further risk?"
- B. "You will need to discuss your concerns about your partner's diet with the provider."
- C. "Everyone likes food from home, but it can delay your partner's recovery."
- D. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
Correct Answer: D
Rationale: The correct answer is D: "Let's try to find ways to incorporate your partner's favorite food into her diet plan." This response acknowledges the partner's desire to bring food from home while also emphasizing the importance of adhering to the client's dietary plan for recovery. By suggesting a compromise to incorporate the favorite food within the diet plan, the nurse is promoting collaboration and patient-centered care. It shows understanding and empathy towards the partner's concerns while prioritizing the client's health and recovery.
Choice A is incorrect as it may come off as judgmental and dismissive. Choice B is not the most appropriate response as it doesn't address the partner's request directly. Choice C is incorrect as it may sound like a blanket statement and could potentially create tension between the nurse and the partner.
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?
- A. A semi-private room across from the day room.
- B. A private room in a quiet location on the unit.
- C. A private room across from the exercise room.
- D. A semi-private room across from the snack area.
Correct Answer: B
Rationale: The correct answer is B: A private room in a quiet location on the unit. This choice minimizes stimuli and provides a calm environment, essential for managing manic symptoms. A quiet location reduces potential triggers for agitation or impulsivity. Semi-private rooms (A, D) may lead to conflicts with roommates. Rooms near common areas (C, D) can be noisy and disruptive. Overall, choice B promotes client safety and well-being during the manic phase.
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
- A. Experiencing diarrhea
- B. Exercising moderately
- C. Increasing sodium intake
- D. Drinking green tea
Correct Answer: A
Rationale: The correct answer is A: Experiencing diarrhea. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood and cause toxicity. This is because lithium is primarily excreted by the kidneys, and dehydration can impair its elimination. Options B, C, and D are incorrect because moderate exercise, increasing sodium intake, and drinking green tea are not known to directly cause lithium toxicity. In fact, maintaining adequate hydration and a balanced diet with normal sodium intake can help prevent lithium toxicity.
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
- A. Anhedonia
- B. Anergia
- C. Anosognosia
- D. Akathisia
Correct Answer: A
Rationale: The correct answer is A: Anhedonia. Anhedonia refers to the inability to experience pleasure or joy, which is a common symptom of depressive disorders. In this case, the client's statement of not feeling happiness or joy directly aligns with the definition of anhedonia.
Choice B, Anergia, refers to lack of energy or motivation, which is not directly related to the client's statement about not feeling happiness or joy. Choice C, Anosognosia, is a lack of awareness or insight into one's own condition, which is not applicable in this scenario. Choice D, Akathisia, refers to a movement disorder characterized by restlessness, which is not related to the client's emotional state.
In summary, Anhedonia is the most appropriate term to use when documenting the client's inability to feel happiness or joy, as it directly reflects their emotional experience in the context of a depressive disorder.
A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?
- A. "Evidence must exist prior to reporting."
- B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it."
- C. "I don't want to defame someone if the report is false."
- D. "If suspicion of abuse exists, then reporting is mandatory."
Correct Answer: D
Rationale: The correct answer is D: "If suspicion of abuse exists, then reporting is mandatory." This statement is correct because as a healthcare professional, it is crucial to report any suspicion of child abuse to protect the child's safety. Reporting is mandatory to ensure that appropriate actions are taken to investigate and prevent harm to the child.
A: "Evidence must exist prior to reporting." - This statement is incorrect because suspicion alone is enough to trigger reporting, and waiting for evidence may delay intervention and put the child at risk.
B: "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." - This statement is incorrect as it is the responsibility of healthcare workers to report suspected abuse regardless of promises made by the potential abuser.
C: "I don't want to defame someone if the report is false." - This statement is incorrect because the focus should be on the safety and well-being of the child, and reporting suspicions of abuse is not about def