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A rape victim asks a nurse, 'How do I know whether this attack was my fault?' Which response by the nurse is therapeutic?
- A. Support the victim to separate issues of vulnerability from blame.
- B. Make decisions for the victim because of the temporary confusion.
- C. Reassure the victim that the outcome of the situation will be positive.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because it focuses on supporting the victim in understanding that vulnerability does not equate to blame. This response helps the victim separate self-blame from the responsibility of the perpetrator. Choice B is incorrect as it undermines the victim's autonomy. Choice C is incorrect as it offers false reassurance and ignores the complexity of the situation. Choice D is incorrect as option A provides a therapeutic response that addresses the victim's emotional needs.
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When are the recommended ages for developmental screening to be done according to AAP guidelines?
- A. 6 months, 12 months, and 18 months
- B. 6 months, 18 months, and 36 months
- C. 18 months, 24 months, and 36 months
- D. 9 months, 18 months, and 30 months
Correct Answer: D
Rationale: The American Academy of Pediatrics (AAP) recommends developmental screening at 9, 18, and 30 months during well-child visits to identify developmental delays early.
When planning nursing care for a client with a dependent personality disorder, the nurse recognizes which of the following as characteristic behavior for someone with this disorder? The client:
- A. Perceives his or her behavior to be embarrassing
- B. Believes he or she cannot function without help of others
- C. Exaggerates the potential dangers of ordinary situations
- D. Demands excessive attention from others
Correct Answer: B
Rationale: The correct answer is B because individuals with dependent personality disorder typically believe they cannot function without the help of others. This is a key characteristic of the disorder as they rely heavily on others for decision-making and day-to-day tasks. This behavior stems from an intense fear of separation and abandonment.
Choice A (perceiving behavior as embarrassing) is incorrect as it is more aligned with social anxiety disorder rather than dependent personality disorder. Choice C (exaggerating dangers) is incorrect as it is more characteristic of individuals with anxiety disorders. Choice D (demanding excessive attention) is incorrect as it is more typical of individuals with histrionic personality disorder.
A nurse is caring for a patient with bulimia nervosa who is experiencing frequent purging. What is a priority assessment?
- A. Monitor electrolyte levels and cardiac function.
- B. Observe for signs of dehydration and low blood pressure.
- C. Assess for any compulsive exercise behaviors.
- D. Monitor for changes in eating patterns and food preferences.
Correct Answer: A
Rationale: The correct answer is A, to monitor electrolyte levels and cardiac function. This is a priority assessment because frequent purging in bulimia nervosa can lead to electrolyte imbalances and cardiac complications, such as arrhythmias and heart failure. Monitoring these parameters is crucial for early detection and intervention to prevent serious health consequences. Observing for signs of dehydration and low blood pressure (Choice B) is important but not as critical as monitoring electrolyte levels and cardiac function. Assessing for compulsive exercise behaviors (Choice C) and monitoring changes in eating patterns and food preferences (Choice D) are also relevant but secondary to the immediate risk of electrolyte imbalances and cardiac issues.
A 45-year-old married woman who works full time in a factory has recently been absent for 3-day periods on several occasions. Each time, she returned to work wearing dark glasses. Facial and body bruises were apparent. Her supervisor became suspicious that she was a victim of battering and referred her to the occupational health nurse. Which initial inquiry would be most important for the nurse to make?
- A. Tell me what has happened to you.'
- B. Did your husband beat you?'
- C. Why do you let this happen?'
- D. What can you do to prevent this?'
Correct Answer: A
Rationale: The correct answer is A: "Tell me what has happened to you." This open-ended question allows the woman to share her experience without judgment or assumptions. It shows empathy and respect for her autonomy. It is crucial for the nurse to gather information directly from the patient to understand the situation fully and provide appropriate support.
Choice B is incorrect because it assumes the woman's husband is the perpetrator without giving her a chance to disclose the information herself. This can be intimidating and may not lead to a truthful response.
Choice C is incorrect because it implies blame on the victim for the abuse, which is not appropriate. It does not focus on providing support or understanding the situation.
Choice D is incorrect as it puts the responsibility on the victim to prevent the abuse, which is not a helpful approach. The focus should be on providing support and understanding the victim's situation.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient is displaying symptoms such as restlessness, disorganized behavior, nonsensical verbal responses, disorientation, hot and dry skin, and dilated pupils, which are indicative of anticholinergic toxicity.
Step-by-step rationale:
1. Restlessness and disorganized behavior are common symptoms of anticholinergic toxicity.
2. Nonsensical verbal responses and disorientation are also typical signs of anticholinergic toxicity.
3. Hot and dry skin can be caused by decreased sweating due to anticholinergic effects.
4. Dilated pupils are a classic sign of anticholinergic toxicity.
5. Checking vital signs and preparing to use a cooling blanket is the appropriate immediate action to manage anticholinergic toxicity.
Summary of other choices:
- B: Relapse of psychosis does not explain the physical symptoms like dilated pupils and hot/dry skin.
- C: Neuroleptic malignant syndrome presents with