A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicates understanding of the teaching?
- A. Survivors of abuse often feel guilty
- B. Abusers often have high self-esteem
- C. The honeymoon stage of violence usually gets longer over time
- D. As abuse continues, victims become more determined to be independent
Correct Answer: A
Rationale: Correct Answer: A: Survivors of abuse often feel guilty
Rationale: This statement indicates understanding of the psychological impact of intimate partner abuse. Guilt is a common emotion experienced by survivors due to manipulation and blame from the abuser. It reflects the internalized self-blame and shame that many survivors struggle with.
Summary of other choices:
B: Abusers often have high self-esteem - Incorrect. Abusers typically have low self-esteem and use abuse as a way to exert power and control.
C: The honeymoon stage of violence usually gets longer over time - Incorrect. The honeymoon phase tends to decrease over time as abuse cycles escalate.
D: As abuse continues, victims become more determined to be independent - Incorrect. Victims often experience increased isolation and dependency on the abuser.
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A nurse is caring for a client who has obsessive-compulsive disorder and engages in repeated handwashing. Which of the following actions should the nurse take?
- A. Encourage the client to stop washing hands
- B. Allow the client additional time to complete rituals
- C. Set strict time limits on compulsions
- D. Ignore the client’s compulsive behavior
Correct Answer: B
Rationale: The correct answer is B: Allow the client additional time to complete rituals. This approach is known as a harm reduction strategy in managing obsessive-compulsive disorder. By allowing the client additional time to complete rituals, the nurse can help reduce the client's anxiety and provide a sense of control. Encouraging the client to stop washing hands (A) may increase anxiety and worsen symptoms. Setting strict time limits on compulsions (C) can also increase anxiety and lead to distress. Ignoring the client's compulsive behavior (D) can be harmful as it may reinforce the behavior. It is important for the nurse to be supportive and understanding of the client's struggles while working towards more effective coping strategies.
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
- A. Weigh the client twice per day
- B. Prepare the client for electroconvulsive therapy
- C. Set a weight gain goal of 2.2kg (5lbs) per week
- D. Encourage the client to participate in family therapy
Correct Answer: C
Rationale: The correct answer is C: Set a weight gain goal of 2.2kg (5lbs) per week. This intervention is appropriate for a client with anorexia nervosa to promote healthy weight restoration. Rapid weight gain can be harmful, so setting a realistic goal helps prevent complications. Weighing the client twice per day (A) can exacerbate anxiety and reinforce obsessive behaviors. Electroconvulsive therapy (B) is not indicated for anorexia nervosa. Encouraging family therapy (D) may be beneficial, but the priority is weight restoration.
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Visual hallucinations
- C. Hyperactivity
- D. Increased appetite
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations, particularly visual ones, due to the impact of alcohol on the brain. This is known as alcohol hallucinosis. Hypotension (choice A) is not typically associated with alcohol withdrawal; in fact, hypertension is more common. Hyperactivity (choice C) is not a common symptom of alcohol withdrawal, as clients tend to be more agitated or restless. Increased appetite (choice D) is also not a typical finding during alcohol withdrawal, as many clients experience decreased appetite. Visual hallucinations are a key symptom to monitor for during alcohol withdrawal due to their potential to be distressing and require immediate intervention.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Provide frequent rest periods
- B. Discourage social interaction
- C. Allow unlimited physical activity
- D. Limit the client's choices
Correct Answer: A
Rationale: The correct answer is A: Provide frequent rest periods. During mania, clients with bipolar disorder have high energy levels and may engage in excessive activities, leading to physical and mental exhaustion. Providing frequent rest periods helps to prevent burnout and promotes relaxation. Choice B is incorrect as social interaction can provide support and prevent feelings of isolation. Choice C is incorrect as unlimited physical activity can exacerbate manic symptoms. Choice D is incorrect as limiting choices can cause frustration and may escalate the manic episode.
A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders?
- A. Dependent
- B. Paranoid
- C. Borderline
- D. Histrionic
Correct Answer: C
Rationale: The correct answer is C: Borderline. Excessive compliance, passivity, and self-denial are characteristic traits of individuals with Borderline Personality Disorder. They often struggle with identity, exhibit intense emotions, and have unstable relationships. Choice A, Dependent Personality Disorder, is characterized by a pervasive psychological dependence on others. Choice B, Paranoid Personality Disorder, involves distrust and suspiciousness. Choice D, Histrionic Personality Disorder, is characterized by attention-seeking behavior and emotional overreaction. Choices E, F, and G are irrelevant. In this scenario, the client's behaviors align most closely with the features of Borderline Personality Disorder.