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A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: Asking the client to describe the hallucinations validates their experience and provides insight into their condition, aiding therapeutic communication. Touching may be intrusive, leaving them alone is non-therapeutic, and denying the voices dismisses their reality.
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During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
- A. inquire about foods the child is eating.
- B. ask about the possibility of sexual abuse.
- C. request to see the type of bottle used for feedings.
- D. question the parent about objects the child plays with.
Correct Answer: B
Rationale: Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechiae) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse.
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. blood
- B. meconium
- C. hydramnios
- D. caput
Correct Answer: B
Rationale: Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.
An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
- A. I think I was a lonely child because I could not tell anyone about my abuse.'
- B. I am now aware of how deep-seated my anger is. Before I did not realize I was angry.'
- C. The program has given me the courage to tell my mother how I felt about her role in my hurt.'
- D. There are so many people just like me, who are just normal people that had bad things happen to them.'
Correct Answer: B
Rationale: Children who are abused learn to cope with the painful experiences by ignoring painful feelings and avoiding getting close to people. As adults, victims of abuse usually continue to repress feelings, avoid close interpersonal relationships, and frequently use alcohol or drugs to block painful memories. Long-term effects in adults might include criminal/violent behavior (for adult males), substance abuse, and a variety of social and emotional problems (including suicidal thoughts, anxiety, hostility, dissociation, and interpersonal difficulties).
The three major sequential maturational crises for females include:
- A. puberty, pregnancy, and menopause.
- B. death of a spouse, menopause, and childbirth.
- C. rape, divorce, and menarche.
- D. dating, engagement, and separation.
Correct Answer: A
Rationale: The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. These are life events that have been studied by many researchers and are considered the major events in a woman's life. Puberty is the onset menarche. Pregnancy is a turning point in one's life from which there is no return. Menopause is the cessation of menses. The nurse has the responsibility to assess, plan, implement appropriate concepts to facilitate effective functioning, and enhance growth and development. Other options are not sequential maturational crises.
How does the ANA define the psychiatric nursing role?
- A. a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art.
- B. assisting the therapist to relieve the symptoms of clients.
- C. to solve clients' problems and give them the answers.
- D. having a client committed to long-term therapy with the nurse.
Correct Answer: A
Rationale: The ANA sets standards of practice for psychiatric and mental health nursing roles. Quality of care, performance appraisal, education, ethics, collaboration, and research are covered through the use of the Nursing Process.