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A patient who has been physically abused says, 'When I called the police, I just wanted my spouse to stop shoving me around and kicking me. I didn't want anyone to get in trouble. It's easy to get angry with me because I spend too much money.' Which nursing intervention would be most therapeutic for this patient?
- A. You feel your spouse was justified in the abuse because you overspent?'
- B. Tell your spouse that if this happens again, I'll report it to the police.'
- C. Your spouse abuses you when you overspend. So you think it will stop if you stop spending money?'
- D. I can understand that you don't want to press charges, but your spouse needs help controlling anger.'
Correct Answer: A
Rationale: The correct answer is A because it focuses on therapeutic communication by reflecting the patient's feelings and thoughts back to them without judgment. By repeating the patient's words, the nurse shows empathy and understanding, which can help build trust and rapport. Choices B and D may escalate the situation and go against the patient's wishes, potentially causing further harm. Choice C assumes a causal relationship between overspending and abuse, which is not appropriate and may blame the victim. Overall, choice A promotes a non-judgmental and supportive environment, which is crucial in addressing issues of abuse.
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A patient is diagnosed with anorexia nervosa. A nurse who is assessing for co-morbid psychiatric disorders should begin by looking for signs of which common, concurrent diagnosis?
- A. Phobias.
- B. Depression.
- C. Schizophrenia.
- D. Personality disorder.
Correct Answer: B
Rationale: The correct answer is B: Depression. Anorexia nervosa commonly co-occurs with depression due to shared risk factors and biological mechanisms. Depression is often a primary trigger or consequence of anorexia nervosa, making it a crucial diagnosis to assess for. Phobias (choice A) may be present but are less commonly associated with anorexia nervosa. Schizophrenia (choice C) and personality disorders (choice D) are less likely to co-occur with anorexia nervosa compared to depression. Identifying and addressing depression in a patient with anorexia nervosa is essential for comprehensive treatment and improved outcomes.
An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?
- A. Ask questions that can be answered with yes or no.
- B. Ask clear, simple questions using concrete language.
- C. Use silence often and let the patient take the lead.
- D. Use open-ended, indirect questions.
Correct Answer: B
Rationale: Communication with individuals who have schizophrenia might be difficult because of their various thought disorders. The nurse can be most effective by using simple language, keeping to concrete concepts, and clarifying and validating as needed (B). Yes/no questions (A) limit information, silence (C) may not engage, and open-ended questions (D) may confuse.
After a person was abducted and raped at gunpoint by an unknown assailant, which trauma syndrome is most likely to occur?
- A. Decreased motor activity.
- B. Confusion and disbelief.
- C. Flashbacks and dreams.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Confusion and disbelief. After experiencing a traumatic event like abduction and rape at gunpoint, it is common for individuals to feel confused and in disbelief due to the overwhelming nature of the experience. This reaction is part of the acute stress response and is a normal psychological defense mechanism. Decreased motor activity (choice A) is less likely to be the immediate response to such a traumatic event. Flashbacks and dreams (choice C) are more characteristic of post-traumatic stress disorder (PTSD), which may develop later on but are not the initial trauma syndrome. Choice D is incorrect as trauma responses are expected in this situation.
A client who was treated for anorexia nervosa is seen by the therapist for a follow-up visit 1 month after discharge from the hospital. Which statement indicates that the client has met the goal 'Demonstrate improvement in body image with more realistic view of body shape and size?'
- A. When I go shopping, I always select clothes that are several sizes too large for me.'
- B. My boyfriend says I really look good now that I'm out of the hospital.'
- C. I had my class picture taken, and I think it looks really good.'
- D. My mother bought me a whole new wardrobe since I've been home.'
Correct Answer: C
Rationale: The correct answer is C because the client's statement reflects a positive and self-affirming perception of themselves. By stating that they think their class picture looks really good, it shows an improvement in body image and a more realistic view of their body shape and size. This indicates progress towards the goal of developing a healthier self-perception.
Choice A is incorrect because selecting clothes that are several sizes too large may still indicate body image distortion and dissatisfaction. Choice B is incorrect because relying on external validation from a boyfriend does not necessarily reflect an internalized improvement in body image. Choice D is incorrect as the mother buying a new wardrobe does not directly address the client's perception of their body image or shape.
A 5-year-old boy is diagnosed in the Emergency Department as having measles, the first symptoms having started 2 days previously. He has a 2-year-old sister, who has received the recommended immunisation schedule. Which one of the following is the most appropriate treatment?
- A. Treat him symptomatically and send him home.
- B. Refer him to the infectious diseases hospital.
- C. Give him gamma globulin.
- D. Give gamma goblin to the sister.
Correct Answer: A
Rationale: Measles is managed symptomatically at home (A) unless complications arise. The vaccinated sister is protected, so hospitalization (B), gamma globulin (C, D), or premature reassurance (E) are unnecessary.