Nokea
A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest?
- A. Determine the nature and extent of the coach's sexual disorder.
- B. Assess the coach's potential for suicide or other self-harm.
- C. Assess the coach's self-perception of problem and needs.
- D. Determine whether other children were harmed.
Correct Answer: B
Rationale: The correct answer is B: Assess the coach's potential for suicide or other self-harm. This is the priority nursing action because the coach may be experiencing intense emotional distress and may be at risk for harming themselves. By assessing for suicidal ideation or self-harm, the nurse can ensure the coach's safety and provide appropriate interventions if needed.
Choice A is incorrect because determining the nature and extent of the coach's sexual disorder is not the priority at this moment. Choice C is also incorrect as assessing the coach's self-perception of the problem and needs can be addressed after ensuring their immediate safety. Choice D is incorrect as determining whether other children were harmed is important but not the priority immediately following the coach's arrest.
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An expected outcome for a client who hears voices telling him he is evil would be that by discharge, client will:
- A. Verbalize the reason the voices say he is evil
- B. Respond verbally to the voices
- C. Identify events that increase anxiety and promote hallucinations
- D. Integrate the voices into his personality structure in a positive manner
Correct Answer: C
Rationale: The correct answer is C because it focuses on addressing the underlying causes of the client's experience of hearing voices and feeling evil. By identifying events that increase anxiety and promote hallucinations, the client can work on reducing these triggers and managing his symptoms effectively. This approach is key for long-term improvement and recovery.
A: Verbalizing the reason the voices say he is evil does not address the root cause of the hallucinations and may not lead to effective coping strategies.
B: Responding verbally to the voices may not be therapeutic and could potentially reinforce the hallucinations.
D: Integrating the voices into his personality structure in a positive manner is not a recommended approach as it could lead to further distress and potentially harmful behaviors.
Which of the following should be considered in the assessment of oppositional behaviours in children?
- A. Peer relationships
- B. Child s developmental stage
- C. Behaviours exhibited at home
- D. All of the above
Correct Answer: D
Rationale: All factorsâ€â€peer relationships, developmental stage, home behavior, and family historyâ€â€are critical in assessing oppositional behaviors comprehensively.
A community health nurse is working with a family in which an elderly woman was neglected by her son and his wife. The elderly woman insists on remaining with the young couple despite the threat of future neglect. Which intervention should be given highest priority?
- A. Identify community resources to decrease the caregivers' stress.
- B. Establish family obligations, client rights, and consequences of abuse and monitor.
- C. Educate the caregivers on the aging process and how to cope with it.
- D. Provide stress management techniques for the caregivers.
Correct Answer: B
Rationale: The correct answer is B because establishing family obligations, client rights, and consequences of abuse is crucial in protecting the elderly woman from neglect. By setting clear boundaries and educating the family on their responsibilities and the consequences of neglect, the nurse can help ensure the woman's safety. This intervention addresses the root cause of the issue and empowers the family to understand and fulfill their duties.
Choice A is incorrect as solely focusing on decreasing caregivers' stress may not address the underlying neglect. Choice C is incorrect as educating caregivers on the aging process does not directly address the neglect issue. Choice D is incorrect as providing stress management techniques does not address the root cause of neglect or establish accountability within the family.
A 5-year-old boy is diagnosed in the Emergency Department as having measles, the first symptoms having started 2 days previously. He has a 2-year-old sister, who has received the recommended immunisation schedule. Which one of the following is the most appropriate treatment?
- A. Treat him symptomatically and send him home.
- B. Refer him to the infectious diseases hospital.
- C. Give him gamma globulin.
- D. Give gamma goblin to the sister.
Correct Answer: A
Rationale: Measles is managed symptomatically at home (A) unless complications arise. The vaccinated sister is protected, so hospitalization (B), gamma globulin (C, D), or premature reassurance (E) are unnecessary.
A client in her early teens who is being treated for irritable bowel syndrome has just disclosed that she has been feeling anxious. For what other condition should the nurse assess this client?
- A. Anxiety.
- B. Depression.
- C. Eating disorder.
- D. None of the above.
Correct Answer: A
Rationale: Step 1: The client disclosed feeling anxious.
Step 2: Anxiety is a common comorbidity with irritable bowel syndrome.
Step 3: Assessing for anxiety allows for holistic treatment.
Step 4: Anxiety can impact the client's physical health.
Step 5: Therefore, assessing for anxiety is crucial.
Summary:
B: Depression - While depression is important, the client disclosed anxiety.
C: Eating disorder - Not directly related to the client's disclosure.
D: None of the above - Incorrect, as assessing for anxiety is necessary.