Nokea
A victim of a sexual assault sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped."Â This behavior is characteristic of:
- A. The acute phase reaction.
- B. The angry stage of rape-trauma syndrome.
- C. A delayed reaction to rape-trauma syndrome.
- D. The long-term phase of rape-trauma syndrome.
Correct Answer: A
Rationale: The correct answer is A: The acute phase reaction. This behavior is characteristic of the immediate emotional response following a traumatic event like sexual assault. The victim may exhibit shock, disbelief, and emotional distress. In this scenario, the victim's reaction of disbelief and repetitive statements align with the acute phase reaction. The other options are incorrect because the angry stage (B) and delayed reaction (C) occur later in the trauma response process, while the long-term phase (D) reflects a more prolonged period of adjustment and coping.
You may also like to solve these questions
Which statement about aging provides the best rationale for focused assessment of elderly patients?
- A. The elderly are usually socially isolated and lonely
- B. Vision, hearing, touch, taste, and smell decline with age
- C. The majority of elderly patients have some form of early dementia
- D. As people age, thinking becomes more rigid and learning is impaired
Correct Answer: B
Rationale: Only the key is a true statement. It cues the nurse to assess sensory function in the elderly patient. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging.
Which nursing strategy leads patients to respond more positivity to limit setting?
- A. Confront the patient with the inappropriateness of the behavior.
- B. Explore with the patient the underlying dynamics of the behavior.
- C. Reflect back to the patient an understanding of the patient's distress.
- D. State clear disapproval of the behavior, and support its consequences.
Correct Answer: C
Rationale: The correct answer is C because reflecting back to the patient an understanding of their distress shows empathy and validation, which can help build rapport and trust. By acknowledging the patient's feelings, it can help them feel heard and understood, leading to a more positive response to limit setting.
Choice A is incorrect because confrontation can lead to defensiveness and resistance. Choice B focuses on exploring underlying dynamics without addressing the immediate behavior. Choice D may come off as judgmental and punitive, potentially escalating the situation.
The experienced nurse assessing a battered woman client uses many open-ended questions during the interview. The rationale for this is that:
- A. The woman will feel more in charge of the interview
- B. Such questions allow for simple yes or no answers when the client is upset
- C. The questions are direct and easily understood by anxious individuals
- D. Clients can refuse to answer when sensitive information is being probed
Correct Answer: A
Rationale: The correct answer is A because using open-ended questions allows the client to express themselves freely, promoting a sense of control and empowerment. This approach helps build trust and rapport, enabling the client to share their experiences more openly. Choice B is incorrect because closed-ended questions limit the client's ability to fully express themselves. Choice C is incorrect as open-ended questions encourage deeper reflection and discussion, which may not be easily understood by anxious individuals. Choice D is incorrect because while clients can refuse to answer sensitive questions, open-ended questions actually encourage them to share more, rather than withhold information.
A nurse and social worker co-lead a reminiscence group for eight old-old and centenarian adults. Which activity is appropriate to include in the group?
- A. Mild aerobic exercise
- B. Singing a song from World War II
- C. Discussing national leadership during the Vietnam War
- D. Identifying the most troubling story in today's newspaper
Correct Answer: B
Rationale: The correct answer is B: Singing a song from World War II. This activity is appropriate because reminiscence therapy involves recalling past memories to enhance well-being in older adults. Singing a song from that era can help trigger positive emotions and memories for the participants.
A: Mild aerobic exercise may not be suitable for all participants due to physical limitations.
C: Discussing national leadership during the Vietnam War might evoke negative emotions or political disagreements.
D: Identifying the most troubling story in today's newspaper could lead to distress and is not conducive to the therapeutic nature of reminiscence therapy.
A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?
- A. Do you recognize the voice you hear?'
- B. How long has this been happening?'
- C. Does what the voice tells you to do frighten you?'
- D. What is the voice telling you to do?'
Correct Answer: D
Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.