Nokea
A rape victim asks a nurse, "How do I know whether this attack was my fault?"Â 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. Pose questions about the rape and help the patient explore why it happened.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy and understanding towards the victim by helping them differentiate between vulnerability and blame. By supporting the victim in separating these issues, the nurse can empower them to recognize that the assault was not their fault, thus promoting healing and recovery.
Choice B is incorrect because making decisions for the victim undermines their autonomy and does not address the victim's emotional needs.
Choice C is incorrect as it offers false reassurance and does not address the victim's feelings of guilt or self-blame.
Choice D is incorrect as it may come off as interrogative and could potentially retraumatize the victim by making them feel responsible for the assault.
You may also like to solve these questions
A patient with many positive symptoms of schizophrenia, whose behavior is disorganized and who is highly anxious, tells the nurse in the psychiatric emergency department, 'You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun.' The patient, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend:
- A. admission to an unlocked residential crisis unit.
- B. inpatient hospitalization on a locked unit.
- C. attending a day treatment program for 4 weeks.
- D. admission to a partial hospital program.
Correct Answer: B
Rationale: The correct answer is B: inpatient hospitalization on a locked unit. This option is the most appropriate given the patient's presentation. The patient is experiencing severe positive symptoms of schizophrenia, such as delusions and disorganized behavior, posing a risk to himself and others by expressing intent to obtain a gun. Additionally, the patient is neglecting basic needs, indicating a need for close monitoring and intervention. Inpatient hospitalization on a locked unit provides a structured and secure environment for intensive treatment, ensuring safety and stabilization.
Incorrect choices:
A: Admission to an unlocked residential crisis unit may not provide the level of monitoring and security needed for a patient with active psychotic symptoms and self-harm potential.
C: Attending a day treatment program for 4 weeks does not address the acute safety concerns and level of impairment displayed by the patient.
D: Admission to a partial hospital program may not offer the round-the-clock supervision and immediate intervention required for someone at risk of harming themselves or others.
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
- A. Are you thinking of harming yourself?
- B. It will take time, but you will feel the same.
- C. Your friends will understand when you explain it was not your fault.
- D. You will be able to find meaning in this experience as time goes on.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.
A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment, saying only, 'I will not eat until I lose enough weight to look thin.' Select the best initial nursing diagnosis.
- A. Anxiety related to fear of weight gain.
- B. Disturbed body image related to weight loss.
- C. Ineffective coping related to lack of conflict resolution skills.
- D. None of the above.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): None of the above is the best initial nursing diagnosis because the patient's symptoms suggest a severe medical condition rather than psychological issues. The yellow skin, cold extremities, low heart rate, extreme low weight, and refusal to eat indicate severe malnutrition and possible organ failure. Therefore, the priority is to address the patient's immediate medical needs, such as restoring electrolyte balance and preventing further complications. Psychological assessments and diagnoses can follow once the patient's physical health is stabilized.
Summary of Other Choices:
A: Anxiety related to fear of weight gain - This choice focuses on psychological factors, but the patient's symptoms indicate severe physical malnutrition rather than anxiety.
B: Disturbed body image related to weight loss - While body image issues may be present, the patient's critical medical condition takes precedence over psychological concerns.
C: Ineffective coping related to lack of conflict resolution skills - This choice does not address the urgency of the patient's physical symptoms and is not the most
In phobia fear of heights is referred to as
- A. Agoraphobia
- B. Acrophobia
- C. Abluntophobia
- D. Opiophobia
Correct Answer: B
Rationale: Acrophobia is the specific term for fear of heights, derived from Greek 'acro' (height) and 'phobos' (fear).
Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a client about self-management?
- A. Teach material in small segments
- B. Use only verbal instruction
- C. Plan the teaching for a time when client is stimulated and busy
- D. Offer opportunities for making a large number of choices
Correct Answer: A
Rationale: The correct answer is A because teaching material in small segments is effective for individuals with cognitive disturbances like schizophrenia, as it helps improve comprehension and retention. Breaking down information into manageable parts reduces cognitive overload and enhances learning. Choice B is incorrect as relying solely on verbal instruction may be challenging for individuals with cognitive deficits. Choice C is incorrect because a stimulated and busy environment may hinder learning for someone with schizophrenia due to difficulty focusing. Choice D is incorrect as offering too many choices can be overwhelming and confusing, especially for those with cognitive disturbances.