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A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply.
- A. Allow the patient to talk at a comfortable pace.
- B. Place the patient in a private room with a caregiver.
- C. Pose questions in nonjudgmental, empathetic ways.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Allow the patient to talk at a comfortable pace. This intervention is appropriate because it promotes the patient's autonomy and empowerment in sharing their experience, which can be therapeutic. It also helps establish trust and rapport, facilitating effective communication and assessment.
Incorrect choices:
B: Placing the patient in a private room with a caregiver can be important for privacy and support but may not be the immediate priority.
C: Posing questions in nonjudgmental, empathetic ways is crucial but may not be as important as allowing the patient to talk at their own pace initially.
D: None of the above is incorrect as allowing the patient to talk is a crucial step in providing appropriate care for a patient who has experienced trauma.
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A nurse is caring for a patient with bulimia nervosa. What is a priority assessment for this patient?
- A. Electrolyte imbalances and cardiac function.
- B. Body image issues and mental health status.
- C. Nutritional status and hydration levels.
- D. Weight changes and exercise patterns.
Correct Answer: A
Rationale: The correct answer is A: Electrolyte imbalances and cardiac function. This is because patients with bulimia nervosa often engage in purging behaviors which can lead to electrolyte imbalances and cardiac complications. Assessing electrolyte levels and cardiac function is crucial to prevent life-threatening complications.
Choice B is incorrect because while body image and mental health are important considerations, they are not the priority assessment in this case. Choice C is also incorrect as nutritional status and hydration levels can be affected, but not as immediately life-threatening as electrolyte imbalances and cardiac issues. Choice D is incorrect as weight changes and exercise patterns may be important, but they are not the priority assessment for a patient with bulimia nervosa.
A 67-year-old woman recently noticed a non-painful lump in the right breast (see image). Which one of the following is the most likely diagnosis?
- A. Subacute mastitis with early abscess formation.
- B. Advanced adenocarcinoma of the breast.
- C. Early intraduct carcinoma with obstruction of ductal ampullae.
- D. Severe fibrocystic disease of the breast (fibroadenosis with multiple cysts).
Correct Answer: B
Rationale: A non-painful breast lump in a 67-year-old is most likely advanced adenocarcinoma (B), a common malignancy in this age group. Mastitis (A) is painful, early carcinoma (C) less likely advanced, and fibrocystic disease (D) or fat necrosis (E) are less typical without specific trauma or cysts.
A client with undifferentiated schizophrenia is readmitted for an acute exacerbation of the disorder. The goal of hospitalization is symptom stabilization. The nurse has documented that, in addition to experiencing auditory hallucinations, the client seems uninterested in activities, has difficulty completing tasks, seems forgetful, and seems puzzled by information and directions given by staff. The nurse's plans for intervention will be effective if these behaviors are attributed to:
- A. Social isolation
- B. Deficient knowledge
- C. Situational low self-esteem
- D. Problems in cognitive functioning
Correct Answer: D
Rationale: The correct answer is D: Problems in cognitive functioning. In undifferentiated schizophrenia, cognitive deficits are common, leading to difficulties in memory, attention, problem-solving, and executive functioning. The client's symptoms of forgetfulness, difficulty completing tasks, being puzzled by information, and auditory hallucinations are indicative of cognitive impairment. Interventions should focus on addressing these cognitive deficits to improve the client's ability to function.
Incorrect choices:
A: Social isolation - This choice does not address the cognitive deficits and symptoms described by the client, such as forgetfulness and difficulty completing tasks.
B: Deficient knowledge - While cognitive deficits may contribute to deficient knowledge, the primary concern in this scenario is the client's cognitive functioning impairments.
C: Situational low self-esteem - This choice does not explain the cognitive deficits and symptoms experienced by the client, which are more indicative of problems in cognitive functioning.
The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:
- A. Level of consciousness
- B. Ability to perform activities of daily living
- C. Degree of reasoning, judgment, and thought processes
- D. Level of functioning memory
Correct Answer: B
Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.
The expected outcome for a patient with a nursing diagnosis of disturbed thought processes is:
- A. The patient will be safe from injury.
- B. The patient will meet basic biological needs.
- C. The patient will achieve optimum cognitive functioning.
- D. The patient will maintain positive interpersonal relationships.
Correct Answer: C
Rationale: The correct answer is C because disturbed thought processes indicate cognitive impairment. Thus, the expected outcome should focus on improving cognitive functioning to achieve optimal mental clarity and decision-making. Safety (A) is important but not directly related to cognitive improvement. Meeting basic needs (B) and maintaining relationships (D) are important but not the primary focus when the diagnosis is disturbed thought processes. So, the priority is on enhancing cognitive functioning to address the root cause of the issue.