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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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When told that he is scheduled to interview a patient with narcissistic personality disorder, the nurse can anticipate the assessment findings will include the following:
- A. charm, drama, seductiveness, and admiration seeking.
- B. preoccupation with minute details and perfectionism.
- C. difficulty being alone, indecisiveness, and submissiveness.
- D. grandiosity, self-importance, and a sense of entitlement.
Correct Answer: D
Rationale: The correct answer is D. In narcissistic personality disorder, individuals exhibit grandiosity, self-importance, and a sense of entitlement. This is a key feature of the disorder where individuals have an inflated sense of their own importance and require excessive admiration. This behavior is often accompanied by a lack of empathy and exploitation of others.
Choice A (charm, drama, seductiveness, and admiration seeking) is more characteristic of histrionic personality disorder.
Choice B (preoccupation with minute details and perfectionism) is more characteristic of obsessive-compulsive personality disorder.
Choice C (difficulty being alone, indecisiveness, and submissiveness) does not align with the typical presentation of narcissistic personality disorder.
A newly admitted patient with schizophrenia approaches the unit nurse and says, 'The voices are bothering me. They are yelling and telling me stuff. They are really bad.' Which response by the nurse would be most appropriate?
- A. Do you hear these voices very often?'
- B. Do you have a plan for getting away from the voices?'
- C. I'll stay with you. Tell me what you are hearing.'
- D. Try to ignore them and play cards with the others.'
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and empathy, which can help establish trust and rapport with the patient. By saying, "I'll stay with you. Tell me what you are hearing," the nurse acknowledges the patient's distress and offers support. This response can help the patient feel heard and understood, which is crucial in managing symptoms of schizophrenia.
Choice A is incorrect as it focuses more on the frequency rather than addressing the immediate distress. Choice B is incorrect as it assumes the patient has a plan to escape the voices, which may not be the case and can escalate the situation. Choice D is incorrect as it dismisses the patient's experience and suggests distraction rather than addressing the underlying issue.
A child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty. When asked about his parents, the child reluctantly reveals that he thinks his father does not like him very much because he calls him 'stupid' and says he can never do anything right. This should be assessed as:
- A. physical abuse.
- B. sexual abuse.
- C. emotional abuse.
- D. economic abuse.
Correct Answer: C
Rationale: Explanation:
C: Emotional abuse is the correct assessment as the father's behavior of calling the child 'stupid' and criticizing him can cause psychological harm. This behavior undermines the child's self-esteem and mental well-being. The child's reluctance to speak about his parents also indicates emotional distress.
Incorrect choices:
A: Physical abuse involves causing physical harm, which is not evident in the scenario.
B: Sexual abuse involves inappropriate sexual behavior, which is not indicated in the scenario.
D: Economic abuse involves financial control or exploitation, which is not the primary issue in this scenario.
Select the best comment for a nurse to begin an interview with an elderly patient.
- A. I am a nurse. Are you familiar with what nurses do?'
- B. Hello. I am going to ask you some questions to get to know you better.'
- C. You look comfortable and ready to participate in an admission interview. Shall we get started?'
- D. Hello. My name is and I am a nurse. How you would like to be addressed by staff?'
Correct Answer: D
Rationale: The correct opening identifies the nurses role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self.
An 82-year-old widow with Alzheimer's disease lives with her daughter's family, which owns a catering business. During the week, the patient attends a daycare center for patients. During the evenings, members of the family care for the patient. One day, the nurse at the daycare center notices the patient's appearance is disheveled and that she has bruises on her wrists and back when escorted to the bathroom. What most likely explains the nurse's observations?
- A. The patient is being neglected and abused within the family.
- B. The dementia is progressing, reducing self-care and increasing falls.
- C. The patient is experiencing normal aging symptoms.
- D. The patient is suffering from a new medical condition.
Correct Answer: A
Rationale: The correct answer is A because the nurse's observations of disheveled appearance, bruises, and signs of physical abuse indicate possible neglect and abuse within the family. This is supported by the presence of Alzheimer's disease, vulnerability due to age, and the patient's living situation with family members who own a catering business. Choice B is incorrect as it does not explain the bruises and neglect observed. Choice C is incorrect as normal aging symptoms would not typically include bruises and neglect. Choice D is incorrect as there is no indication of a new medical condition causing these specific observations.