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A patient whose boyfriend raped her during an argument tells the nurse, 'It's no use reporting it. No one will ever believe me, because everyone knows I've been sexually intimate with him many times before.' Which response by the nurse would have the greatest therapeutic value initially?
- A. You will need to talk to someone. Do you have a best friend to talk to?'
- B. It's not your fault. He needs to get help controlling his anger.'
- C. The police need to be aware that your boyfriend is willing to act this way when he's angry.'
- D. If you said 'no,' your boyfriend needs to respect your wishes. He needs help so this will never happen again.'
Correct Answer: D
Rationale: Rationale for Correct Answer D:
1. Acknowledges the patient's agency and emphasizes consent.
2. Validates the patient's experience and emphasizes boundaries.
3. Encourages the patient to prioritize her safety and well-being.
4. Addresses the need for intervention and prevention of future harm.
Summary:
A: Does not address the issue of consent or the need for intervention.
B: Shifts focus from perpetrator to victim, potentially placing blame.
C: Focuses on legal action without addressing the patient's emotional needs.
D: Empowers the patient, emphasizes consent, and prioritizes safety and prevention.
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Which of the following is a priority for a nurse caring for a patient with anorexia nervosa during the refeeding phase?
- A. Providing a high-calorie diet immediately to speed up weight gain.
- B. Monitoring the patient closely for signs of refeeding syndrome.
- C. Promoting the patient's independence in meal choices.
- D. Encouraging exercise to improve physical health.
Correct Answer: B
Rationale: The correct answer is B: Monitoring the patient closely for signs of refeeding syndrome. Refeeding syndrome is a potentially life-threatening condition that can occur when a malnourished individual is fed too quickly. Monitoring for signs such as electrolyte imbalances, fluid shifts, and organ dysfunction is crucial to prevent complications. Providing a high-calorie diet immediately (A) can exacerbate refeeding syndrome. Promoting independence in meal choices (C) may not be appropriate if the patient needs close monitoring. Encouraging exercise (D) can be harmful during the refeeding phase as the body needs time to recover and regain strength.
Which intervention would be appropriate for a patient with a nursing diagnosis of Ineffective coping as evidenced by manipulation of others?
- A. Refer patient requests and questions about care to the primary nurse.
- B. Provide negative reinforcement for any acting-out behavior.
- C. Ignore rather than confront inappropriate interpersonal behavior.
- D. Encourage the patient to discuss feelings of fear and inferiority.
Correct Answer: A
Rationale: The correct answer is A because referring patient requests and questions about care to the primary nurse promotes patient independence and helps establish boundaries. This intervention empowers the patient to take responsibility for their care and reduces the reliance on manipulation of others.
Choice B is incorrect because negative reinforcement may exacerbate the behavior and lead to further manipulation.
Choice C is incorrect because ignoring inappropriate behavior does not address the underlying issue of ineffective coping and may reinforce the behavior.
Choice D is incorrect because encouraging the patient to discuss feelings of fear and inferiority may be helpful, but it does not directly address the manipulation of others, which is the main concern in this nursing diagnosis.
The inability to fall asleep or stay asleep is called:
- A. Insomnia.
- B. Narcolepsy.
- C. Hypersomnia.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Insomnia. Insomnia refers to the inability to fall asleep or stay asleep, leading to difficulties in getting enough sleep. It is a common sleep disorder affecting many people. Narcolepsy (B) is a disorder characterized by excessive daytime sleepiness and sudden sleep attacks. Hypersomnia (C) is a condition involving excessive daytime sleepiness but differs from insomnia. Choice D is incorrect as the term "insomnia" precisely describes the inability to fall or stay asleep.
An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, 'Its awful to be old. Every day is a struggle. No one cares about old people.' Select the nurses best response.
- A. Everyone here cares about old people. Thats why we work here.'
- B. It sounds like youre having a difficult time. Tell me about it.'
- C. Lets not focus on the negative. Tell me something good.'
- D. You are still able to get around, and your mind is alert.'
Correct Answer: B
Rationale: The nurse uses empathetic understanding to permit the patient to express frustration and clarify her struggle for the nurse. The distracters block communication.
In autistic spectrum disorder when as individual exhibits immediate imitation of words or sounds they have just heard, this is known as:
- A. Echoastic disorder
- B. Phonological inhibition
- C. Echolalia
- D. Grapheme dysfunction
Correct Answer: C
Rationale: Echolalia: The immediate imitation of words or sounds heard, a common feature in autistic spectrum disorder.