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A rape victim tells the emergency room nurse, "I feel so dirty. Help me take a shower before the doctor examines me."Â The nurse should:
- A. Arrange for the patient to shower.
- B. Explain that bathing would destroy evidence.
- C. Give the patient a basin of water and towels.
- D. Explain that bathing facilities are not available in the emergency department.
Correct Answer: B
Rationale: The correct answer is B: Explain that bathing would destroy evidence. This is the correct choice because bathing can potentially wash away crucial forensic evidence that can be collected during a sexual assault examination. Preserving evidence is essential for legal proceedings and ensuring justice for the victim.
Choice A is incorrect because arranging for the patient to shower would destroy evidence. Choice C is incorrect as giving the patient a basin of water and towels would still risk destroying evidence. Choice D is also incorrect as it does not address the importance of preserving evidence in cases of sexual assault.
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A client who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother describes her as shy and having few friends. Which would be an appropriate nursing diagnosis for this client?
- A. Anxiety related to a new environment as evidenced by isolation and not talking with peers
- B. Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers
- C. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others
- D. Disturbed thought processes related to a new environment as evidenced by isolation and minimal interactions with others
Correct Answer: B
Rationale: The correct answer is B: Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers. This is the most appropriate nursing diagnosis for the client because it accurately reflects the client's behavior of isolation and lack of communication with peers, which are indicative of impaired social interaction.
Rationale:
1. Impaired social interaction is a key characteristic of schizoid personality disorder, as individuals with this disorder tend to be socially isolated and have difficulty forming relationships.
2. The client's behavior of not speaking to peers and sitting through meetings without interaction supports the diagnosis of impaired social interaction.
3. The description of the client by her mother as shy and having few friends further supports the diagnosis of impaired social interaction.
Summary:
A: Anxiety related to a new environment is incorrect because the client's behavior is more indicative of impaired social interaction rather than anxiety.
C: Ineffective coping related to new environment is incorrect as there is no evidence to suggest that the client is using maladaptive coping
Behavioral problems in which the person exhibits symptoms suggesting physical disease or injury, but for which there is no identifiable cause, are called
- A. mood disorders
- B. schizophrenia
- C. organic brain pathologies
- D. somatoform disorders
Correct Answer: D
Rationale: Somatoform disorders feature physical complaints without medical explanation.
A client frequently impulsively acts out suicidal impulses, including grabbing the coffee jar to smash it and attempting to hang herself with her bra. The nurse would view the client's behaviors as most consistent with:
- A. Narcissistic personality disorder
- B. Histrionic personality disorder
- C. Borderline personality disorder
- D. Antisocial personality disorder
Correct Answer: C
Rationale: The correct answer is C: Borderline personality disorder. The client's impulsive and self-destructive behaviors, such as attempting suicide, are characteristic of individuals with borderline personality disorder. These individuals often struggle with intense emotions, unstable relationships, and have a fear of abandonment. They may engage in self-harming behaviors as a way to cope with emotional distress.
A: Narcissistic personality disorder is characterized by a grandiose sense of self-importance and a lack of empathy. This does not align with the impulsive and self-destructive behaviors described in the scenario.
B: Histrionic personality disorder is characterized by attention-seeking behaviors and excessive emotions. While there may be some overlap with impulsive behaviors, it does not fully capture the severity and self-destructiveness of the client's actions.
D: Antisocial personality disorder is characterized by a disregard for the rights of others and a lack of remorse. While individuals with this disorder may engage in impulsive behaviors, the specific behaviors described in
What should the nurse focus on when planning care for a patient with anorexia nervosa?
- A. Encourage the patient to restrict food intake and control weight.
- B. Provide a structured meal plan and monitor nutritional intake.
- C. Allow the patient to eat freely without any food restrictions.
- D. Encourage daily exercise to help manage weight.
Correct Answer: B
Rationale: The correct answer is B because providing a structured meal plan and monitoring nutritional intake is crucial in the care of a patient with anorexia nervosa to ensure they receive adequate nutrition. By following a structured plan, the patient can gradually restore a healthy relationship with food and gain weight safely. Encouraging the patient to eat freely (choice C) can lead to further disordered eating behaviors. Encouraging food restriction and weight control (choice A) can worsen the patient's condition. Encouraging daily exercise (choice D) may exacerbate the patient's excessive focus on weight and body image. In summary, choice B is the best option as it focuses on promoting healthy eating habits and addressing the nutritional needs of the patient with anorexia nervosa.
The sibling of a patient who was diagnosed with a serious mental illness asks why a case manager has been assigned. The nurses reply should cite the major advantage of the use of case management as:
- A. The case manager can modify traditional psychotherapy for homeless patients so that it is more flexible.
- B. Case managers coordinate services and help with accessing them, making sure the patients needs are met.
- C. The case manager can focus on social skills training and esteem building in the real world where the patient lives.
- D. Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money.
Correct Answer: B
Rationale: Case managers coordinate services and access (B), overcoming obstacles for the mentally ill, making it the primary advantage. Other options (A, C, D) are less central to their role.