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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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Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis?
- A. Weight, muscle, and fat congruence with height, frame, age, and sex.
- B. Calorie intake within required parameters of treatment plan.
- C. Weight at established normal range for the patient.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because disturbed body image in an eating disorder patient involves a discrepancy between their perceived body image and reality. Monitoring weight, muscle, and fat congruence with height, frame, age, and sex helps assess if the patient's perception aligns with their actual physical state. Choice B focuses solely on calorie intake, which does not directly address body image perception. Choice C only considers weight, neglecting the importance of muscle and fat distribution in body image perception. Choice D is incorrect as option A is the most relevant outcome indicator for disturbed body image in this scenario.
Emphasize that the battering pattern usually remains the same in frequency and severity.
- A. By emphasizing that the battering pattern usually remains the same in frequency, it indicates a consistent and recurring nature of the behavior in question.
- B. The battering pattern may change over time.
- C. The battering pattern is unpredictable.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because emphasizing that the battering pattern usually remains the same in frequency highlights the consistent and recurring nature of the behavior. This implies that the pattern is predictable and stable. Choice B is incorrect because it contradicts the idea of consistency in the battering pattern. Choice C is incorrect because it suggests unpredictability, which goes against the notion of the pattern remaining the same. Choice D is incorrect because option A aligns with the concept of the battering pattern being consistent in frequency and severity.
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.
Persons who suffer from paraphilias are categorized as having
- A. somatoform disorders
- B. generalized anxiety
- C. sexual disorders
- D. personality disorders
Correct Answer: C
Rationale: Paraphilias are classified as sexual disorders, involving atypical sexual interests causing distress or harm.
The nurse notes that a male client, who is taking an antipsychotic medication, is constantly moving from chair to chair during a group activity, and he complains that he feels 'nervous and jittery inside.' The nurse is aware that this client most likely is experiencing:
- A. Akinesia
- B. Dystonia
- C. Dyskinesia
- D. Akathisia
Correct Answer: D
Rationale: The correct answer is D: Akathisia. Akathisia is a common side effect of antipsychotic medications characterized by an inner feeling of restlessness and an inability to sit still. In this case, the client's constant movement and complaints of feeling 'nervous and jittery inside' align with the symptoms of akathisia.
A: Akinesia refers to a lack of movement or muscle weakness, which is not consistent with the client's presentation.
B: Dystonia is a movement disorder characterized by involuntary muscle contractions, typically presenting as sustained muscle contractions or abnormal postures.
C: Dyskinesia refers to abnormal, involuntary movements, which are not reflective of the client's symptoms in this scenario.
In summary, the client's symptoms of restlessness and inability to sit still indicate that he is likely experiencing akathisia, making option D the correct choice.