Nokea
A person diagnosed with a serious mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority?
- A. Find supported employment
- B. Develop a trusting relationship
- C. Administer prescribed medication
- D. Teach appropriate health care practices
Correct Answer: B
Rationale: Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.
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An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply.
- A. Body map.
- B. DNA swabs.
- C. Photographs.
- D. Pulse oximeter.
Correct Answer: A
Rationale: The correct answer is A: Body map. In cases of sexual assault, a body map is essential to document and track injuries and evidence. It helps in accurately recording the location and nature of injuries on the victim's body. DNA swabs and photographs are also important for collecting forensic evidence. DNA swabs can help in identifying the perpetrator, while photographs can visually document injuries and evidence. However, a pulse oximeter is not typically needed for collecting forensic evidence in cases of sexual assault. It is used to measure oxygen saturation in the blood and is not directly relevant to documenting forensic evidence in this context.
Older adults have reached Erikson's developmental stage of ego integrity when they:
- A. acknowledge that one cannot get everything one wants in life
- B. assess their lives and identify actions that had value and purpose
- C. express a wish that life could be relived differently
- D. feel that they are being punished for things they did not do
Correct Answer: B
Rationale: Ego integrity involves reflecting on life with acceptance and finding meaning, per Erikson's theory.
Which situation would be most likely to serve as a trigger to a catastrophic reaction in a client with stage 2 Alzheimer's disease?
- A. Participating in singing 'Happy Birthday' to another client at dinner
- B. Being scolded by an aide for spilling a glass of milk
- C. Listening to Big Band music from the 1940s
- D. Eating cupcakes in the activities room
Correct Answer: B
Rationale: The correct answer is B because being scolded for spilling milk can trigger feelings of shame, embarrassment, and confusion in a person with Alzheimer's stage 2. This negative interaction can lead to heightened agitation, aggression, or emotional distress due to the client's impaired ability to process and regulate emotions. In contrast, choices A, C, and D involve positive or neutral activities that are less likely to evoke such strong negative emotions or reactions in someone with Alzheimer's disease.
A man who reports frequently experiencing premature ejaculation tells the nurse, 'I feel like such a failure. It's so awful for both me and my partner. Can you help me?' Select the nurse's best response.
- A. Have you discussed this problem with your partner?
- B. I can refer you to a practitioner who can help you with this problem.
- C. Have you asked your health care provider for prescription medication?
- D. There are several techniques described in this pamphlet that might be helpful.
Correct Answer: B
Rationale: The correct answer is B because the nurse should refer the patient to a practitioner who specializes in treating premature ejaculation. This is the best response as it ensures the patient receives specialized care and treatment tailored to his needs. Referring to a specialist increases the likelihood of successful intervention and addresses the patient's concerns effectively.
Choices A, C, and D are incorrect. Choice A focuses on communication with the partner, which is important but not the primary intervention for premature ejaculation. Choice C suggests prescription medication without exploring other treatment options or assessing the patient's individual situation. Choice D provides general information without addressing the patient's emotional distress or offering specific help from a professional.
Mood disorders are those in which the person may
- A. experience severe depression and threaten suicide
- B. exhibit symptoms suggesting physical disease or injury but for which there is no identifiable cause
- C. exhibit behavior that is the result of an organic brain pathology
- D. experience delusions and hallucinations
Correct Answer: A
Rationale: Mood disorders, like depression, feature extreme emotional states, including suicidal ideation.