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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 client, age 42, has been battered by her husband since they were married 8 years ago. Until this hospitalization for major depression, she had avoided dealing with her situation, but she now expresses a desire to deal with the problem. The attacks are occurring more often. Which outcome is realistic for the client?
- A. Citing possible ways she may have contributed to the abusive episodes
- B. Verbalizing an awareness of her increasingly dangerous situation
- C. Setting a goal date for divorcing her husband
- D. Employing methods of retaliating in order to get even with her husband
Correct Answer: B
Rationale: The correct answer is B: Verbalizing an awareness of her increasingly dangerous situation. This choice is the most realistic outcome for the client as it shows an initial step towards acknowledging the severity of her situation. By verbalizing awareness, the client can begin to understand the potential dangers she faces, which is crucial for developing a safety plan and seeking appropriate help.
Choice A is incorrect as it may lead to victim-blaming and does not address the root cause of the abuse. Choice C is premature as setting a goal date for divorcing her husband requires careful planning and consideration of various factors. Choice D is inappropriate as retaliation can escalate the violence and put the client at further risk.
In summary, choice B is the best option as it focuses on increasing the client's awareness of her situation, which is a crucial first step towards addressing and eventually overcoming the abusive relationship.
What is the most effective intervention to address the disturbed body image in patients with anorexia nervosa?
- A. Help the patient engage in self-care routines.
- B. Provide psychotherapy to address the patient's perceptions.
- C. Encourage participation in group activities that require social interaction.
- D. Support the patient in selecting appropriate meals.
Correct Answer: B
Rationale: The correct answer is B because psychotherapy helps address the underlying psychological factors contributing to the disturbed body image in anorexia nervosa. Specifically, cognitive-behavioral therapy can challenge distorted thoughts about body image. Self-care routines (A) may not directly address the root cause. Group activities (C) may not target individual concerns effectively. Supporting meal selection (D) does not address the psychological aspect of body image distortion. In summary, psychotherapy is crucial in addressing the complex psychological issues associated with body image in anorexia nervosa.
A novice nurse tells the assigned mentor, 'I admitted a patient today who has several bizarre delusions. I wanted to tell the patient that the ideas and conclusions simply are not logical. What do you think will happen if I do?' Which reply by the mentor is best?
- A. I think you'll give the patient something to think about.'
- B. The patient will probably incorporate you into the delusions as a persecutor.'
- C. Develop trust using empathy and calmness before pointing out discrepancies.'
- D. Initially, it would be better to go along with the patient's thinking to gain cooperation.'
Correct Answer: C
Rationale: Step 1: Establish trust - Developing trust with the patient is crucial in building a therapeutic relationship.
Step 2: Use empathy and calmness - Showing empathy helps the patient feel understood and valued.
Step 3: Point out discrepancies - Once trust is established, gently pointing out discrepancies in a non-confrontational manner can help the patient reflect on their delusions.
Summary: Choice C is the best because it emphasizes the importance of building trust and rapport before addressing the patient's delusions. Choices A, B, and D are incorrect because they do not prioritize the therapeutic relationship or show empathy towards the patient's experiences.
A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.
- A. Replace personal clothing with gym clothes that all match each other.
- B. Label the patient's clothing with his name and name of the item.
- C. Provide clothing with elastic waistbands and hook-and-loop closures.
- D. None of the above.
Correct Answer: A
Rationale: Rationale: Option A is correct because replacing personal clothing with matching gym clothes simplifies dressing, reducing confusion for a patient with Alzheimer's. This intervention promotes independence and minimizes frustration. Labeling clothing (Option B) may help in identifying items but does not address the deficit. Clothing with elastic waistbands and closures (Option C) may be helpful but does not directly address the deficit. "None of the above" (Option D) is incorrect as Option A is an appropriate intervention.
What is the most important aspect of refeeding for a patient with anorexia nervosa?
- A. Refeeding should begin slowly to avoid complications.
- B. Rapid weight gain is essential to restore health.
- C. The patient should be encouraged to make independent food choices.
- D. Fluid intake should be restricted to avoid water retention.
Correct Answer: A
Rationale: The correct answer is A because refeeding should start slowly to prevent refeeding syndrome, a potentially life-threatening condition caused by rapid electrolyte shifts. Gradually increasing caloric intake allows the body to adjust and reduces the risk of complications. Rapid weight gain (B) is not recommended as it can lead to medical complications. Encouraging independent food choices (C) may not be suitable initially as structured meal plans are often necessary. Restricting fluid intake (D) is not advisable as adequate hydration is crucial during refeeding.