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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.
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The first step in the treatment of incest is to:
- A. believe the child who reports the activity
- B. notify the proper authorities
- C. objectively confront the accused family member
- D. remove the child from the home
Correct Answer: A
Rationale: Believing the child establishes trust and validates their experience, forming the foundation for further protective and therapeutic actions.
In an art therapy session, a client with anorexia nervosa was asked to draw a picture of herself. Which drawing would likely depict the client's view of herself?
- A. A tall, slim girl with obvious muscle definition.
- B. A malnourished teenager with thin, lanky extremities.
- C. A grossly obese figure lacking feminine characteristics.
- D. A shapely figure of a model who she admires.
Correct Answer: C
Rationale: The correct answer is C because individuals with anorexia nervosa often have a distorted body image and see themselves as larger than they actually are. Drawing a grossly obese figure lacking feminine characteristics reflects the distorted self-perception common in anorexia nervosa. Choice A is incorrect as it portrays a positive body image. Choice B may be close, but it focuses more on malnourishment rather than distorted body image. Choice D is incorrect as it reflects admiration for a shapely figure, which may not align with the client's self-perception.
A client, age 70, was brought into the Emergency Department by family members who reported a fall. During the assessment, the nurse became suspicious that the client had suffered physical abuse. The client denied that she had been abused. Her denial is most likely based on her:
- A. Fear of retaliation.
- B. Emotional response to the situation.
- C. Cognitive impairment.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Emotional response to the situation. The client's denial is likely due to emotional factors such as shame, embarrassment, or fear of causing trouble for family members. This emotional response can lead the client to deny abuse even when it has occurred. Choice A is incorrect because fear of retaliation may be a factor, but emotional response is more likely. Choice C is incorrect as cognitive impairment would affect the client's ability to understand and respond to the situation, not necessarily lead to denial. Choice D is incorrect as the client's denial is influenced by emotional factors.
Which complication is most likely in a patient with bulimia nervosa who purges frequently?
- A. Dehydration and electrolyte imbalances.
- B. Increased appetite and weight gain.
- C. Improved digestion and nutrient absorption.
- D. High blood pressure and rapid heart rate.
Correct Answer: A
Rationale: The correct answer is A: Dehydration and electrolyte imbalances. Purging in bulimia nervosa involves self-induced vomiting or misuse of laxatives, leading to fluid and electrolyte loss. This can result in dehydration, electrolyte imbalances, and potentially life-threatening complications like cardiac arrhythmias. Increased appetite and weight gain (B) are less likely due to purging. Improved digestion and nutrient absorption (C) are not associated with frequent purging. High blood pressure and rapid heart rate (D) may occur in severe cases but are not the most likely complication.
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.