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A patient whose history includes experiences with abusive partners is being treated for major depressive disorder. The patient's care plan includes rape-trauma syndrome among its nursing diagnoses. What goal is directly associated with this diagnosis?
- A. Remains free from self-harm
- B. Wears appropriate clothing
- C. Reports feeling stronger and having a sense of hopefulness
- D. Demonstrates appropriate affect for both positive and negative emotions
Correct Answer: C
Rationale: The correct answer is C: Reports feeling stronger and having a sense of hopefulness. This goal is directly associated with rape-trauma syndrome as it focuses on the patient's emotional healing and empowerment. By reporting feeling stronger and having hope, the patient is demonstrating progress towards recovery from the trauma. Choice A is incorrect because remaining free from self-harm is more related to monitoring safety rather than addressing the emotional impact of the trauma. Choice B is irrelevant as wearing appropriate clothing does not directly address the emotional healing process. Choice D is incorrect as demonstrating appropriate affect does not specifically target the psychological aspect of overcoming trauma.
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During a therapy session, a patient is asked to rate the intensity of his current issue from 1 to 10 with 1 being complete absence of the issue and 10 being the most intense. The patient is being asked which type of question?
- A. Relationship
- B. Miracle
- C. Scaling
- D. Exception
Correct Answer: C
Rationale: The correct answer is C: Scaling. Scaling questions involve asking clients to rate the intensity of their issues on a numerical scale, just like in this scenario. This helps therapists understand the perceived severity of the problem and track changes over time. Relationship questions focus on interpersonal dynamics, miracle questions explore ideal outcomes, and exception questions inquire about times when the issue is not present. In this case, the question about rating intensity aligns best with the scaling technique.
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
- A. Use of substances 6 hours before the assessment
- B. Speech patterns
- C. Availability of support resources
- D. Amount of sleep in past 24 hours
Correct Answer: A
Rationale: The correct answer is A: Use of substances 6 hours before the assessment. This is important to assess as substance use can increase the risk of impulsive behavior and exacerbate suicidal thoughts. It is crucial to determine if the individual has recently used substances as it may impact their judgment and decision-making. The other choices are not directly related to immediate risk assessment for suicide. Speech patterns (B) may provide insight into the individual's mental state, but substance use takes precedence in assessing immediate risk. Availability of support resources (C) is important for long-term prevention but does not address immediate risk. The amount of sleep in the past 24 hours (D) may impact mental health but does not directly assess immediate risk of suicide.
The statement"Growth involves resolution of critical tasks through the eight stages of the life cycle" is a concept of which therapeutic model?
- A. Interpersonal.
- B. Cognitive-behavioral.
- C. Intrapersonal.
- D. Psychoanalytic.
Correct Answer: A
Rationale: The correct answer is A: Interpersonal. This concept aligns with Erikson's psychosocial theory, which emphasizes the importance of resolving developmental tasks at each stage of life. Interpersonal therapy focuses on relationships and interactions with others, making it the most suitable model for addressing growth through the life cycle. Choice B (Cognitive-behavioral) focuses on thoughts and behaviors, not developmental stages. Choice C (Intrapersonal) refers to self-awareness and understanding, not specifically addressing life stages. Choice D (Psychoanalytic) focuses on unconscious processes and early childhood experiences, not necessarily on resolving tasks through different life stages.
A client is prescribed disulfiram as part of his alcohol treatment program to prevent relapse. The client asks the nurse, 'How will this drug help me?' Which response by the nurse would be most appropriate?
- A. It will help to cure your alcoholism.'
- B. It can help to prevent you from drinking.'
- C. It makes the withdrawal symptoms less troublesome.'
- D. It helps to clear the alcohol out of your body.'
Correct Answer: B
Rationale: The correct answer is B: It can help to prevent you from drinking. Disulfiram works by causing unpleasant symptoms (such as nausea, vomiting, and headache) when alcohol is consumed, acting as a deterrent to drinking. This helps the client stay sober and avoid relapse.
Incorrect choices:
A: It will help to cure your alcoholism - Disulfiram does not cure alcoholism but helps manage it.
C: It makes the withdrawal symptoms less troublesome - Disulfiram does not address withdrawal symptoms.
D: It helps to clear the alcohol out of your body - Disulfiram does not clear alcohol from the body but rather prevents its metabolism, leading to adverse effects if alcohol is consumed.
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?
- A. Offering hope allays and defuses the patient's anxiety.
- B. Concerns stated aloud become less overwhelming and help problem solving begin.
- C. Anxiety is reduced by focusing on and validating what is occurring in the environment.
- D. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
Correct Answer: B
Rationale: The correct answer is B because verbalizing feelings and concerns can help the patient process and understand their emotions, making them feel less overwhelming. This can facilitate problem-solving by breaking down complex issues into smaller, manageable parts. By talking about their concerns, the patient can also receive support and feedback from the nurse, leading to a sense of relief and empowerment.
Incorrect answer explanations:
A: Offering hope may be comforting but does not directly address the patient's current anxiety by helping them process and verbalize their feelings.
C: Focusing on the environment may not necessarily address the patient's internal feelings and concerns, which are key in managing anxiety.
D: While exploring alternatives can increase a sense of control, it may not directly address the immediate need to process and verbalize emotions to reduce anxiety.