Nokea
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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A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
After describing the various legislative efforts to address the issue of homelessness in the United States, a nursing instructor determines that the teaching was successful when the students identify which of the following as addressing the need for a continuum of care approach?
- A. Bringing Home America Act
- B. Affordable Care Act
- C. American Recovery and Reinvestment Act
- D. McKinney-Vento Homeless Assistance Act
Correct Answer: D
Rationale: The correct answer is D: McKinney-Vento Homeless Assistance Act. This act addresses the need for a continuum of care approach by providing federal funding for homeless assistance programs that offer a range of services to individuals experiencing homelessness. It emphasizes the importance of coordination among various service providers to ensure a seamless transition from emergency shelters to permanent housing.
Choice A: Bringing Home America Act does not specifically focus on homeless assistance programs or the continuum of care approach.
Choice B: Affordable Care Act primarily focuses on healthcare reform and expanding access to healthcare services, not specifically related to addressing homelessness.
Choice C: American Recovery and Reinvestment Act aims to stimulate economic recovery through job creation and infrastructure projects, not directly related to addressing homelessness or providing a continuum of care approach.
A client on a psychiatric unit says,"It's a waste of time to be here. I can't talk to you or anyone." Which would be an appropriate therapeutic nursing response?
- A. "I find that hard to believe."
- B. "Are you feeling that no one understands?"
- C. "I think you should calm down and look on the positive side."
- D. "Our staff here is excellent, and you are in good hands."
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and encourages the client to express their feelings. By asking if the client feels that no one understands, the nurse acknowledges the client's emotions and opens the door for further discussion. Choice A is confrontational and may make the client defensive. Choice C dismisses the client's feelings and is not validating. Choice D is a vague reassurance that does not address the client's concerns.
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.
As a nurse working in obstetrics, what is one way to mitigate possible causes of intellectual disability?
- A. Explain to the parent the treatment options available.
- B. Explain to the parent environmental risks to avoid during pregnancy.
- C. Explain to the parent that genetics have a role in this disability.
- D. Explain to the parent that learning disabilities often go unnoticed until the child enters school.
Correct Answer: B
Rationale: The correct answer is B because avoiding environmental risks during pregnancy can help mitigate possible causes of intellectual disability. Environmental factors such as exposure to toxins, infections, and poor nutrition can have a significant impact on fetal brain development. By educating parents about these risks, nurses can empower them to make informed choices to protect their baby's cognitive development.
Choice A is incorrect because treatment options are not preventive measures to avoid intellectual disability.
Choice C is incorrect because while genetics can play a role in intellectual disability, it is not something parents can actively mitigate during pregnancy.
Choice D is incorrect because learning disabilities are different from intellectual disabilities, and addressing them at school age is not a preventive measure during pregnancy.