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A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
- A. Are you thinking of harming yourself?
- B. It will take time, but you will feel the same.
- C. Your friends will understand when you explain it was not your fault.
- D. You will be able to find meaning in this experience as time goes on.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.
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The nurse is assessing a patient with anorexia nervosa. What is the most important physical examination finding to monitor?
- A. Blood pressure and heart rate.
- B. Height and weight changes.
- C. Skin turgor and hydration status.
- D. Respiratory rate and lung function.
Correct Answer: B
Rationale: The correct answer is B: Height and weight changes. In anorexia nervosa, monitoring height and weight changes is crucial as it reflects the patient's nutritional status and overall health. Weight loss and changes in height can indicate severe malnutrition and potential complications. Blood pressure and heart rate (choice A) can be affected by various factors in anorexia nervosa but may not directly reflect the patient's nutritional status. Skin turgor and hydration status (choice C) are important indicators of hydration levels but may not provide a comprehensive assessment of the patient's nutritional status. Respiratory rate and lung function (choice D) are important, but they may not be the most critical physical examination findings to monitor in anorexia nervosa.
The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting?
- A. Lying to other patients
- B. Flattering the nursing staff
- C. Verbally abusing other patients
- D. Superficiality during counseling
Correct Answer: C
Rationale: The correct answer is C: Verbally abusing other patients should be the priority focus of limit setting. This behavior poses a direct threat to the safety and well-being of other patients. By addressing verbal abuse first, the nurse can establish boundaries and maintain a safe environment for all patients. Lying to other patients (A) may be addressed but is not as immediate a concern. Flattering the nursing staff (B) is manipulative but not as harmful as verbal abuse. Superficiality during counseling sessions (D) may indicate other issues but is not as urgent as addressing the verbal abuse.
What is the primary nursing intervention for a patient with anorexia nervosa who is refusing to eat?
- A. Offer rewards for eating meals.
- B. Provide firm encouragement and offer small, frequent meals.
- C. Enforce strict diet control and limit food choices.
- D. Allow the patient to skip meals if they do not feel hungry.
Correct Answer: B
Rationale: The correct answer is B because providing firm encouragement and offering small, frequent meals is a supportive approach to help the patient with anorexia nervosa overcome their fear of eating. It helps in gradually reintroducing food, building trust, and establishing a healthier eating pattern. Offering rewards (A) may reinforce unhealthy eating behaviors. Enforcing strict diet control (C) can exacerbate control issues and worsen the patient's condition. Allowing the patient to skip meals (D) can perpetuate malnutrition and reinforce avoidance behaviors.
The wife of a client who is being seen in the sleep clinic states that her husband snores terribly at night and that she has to shake him to get him to stop. The client complains of a headache upon wakening and often falls asleep during the day when he sits for long periods. This client is exhibiting signs and symptoms characteristic of:
- A. Narcolepsy.
- B. Parasomnia.
- C. Sleep apnea.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Sleep apnea. This client is showing classic signs of obstructive sleep apnea, including loud snoring, waking up with headaches, and excessive daytime sleepiness. Snoring and the need for physical stimulation to stop snoring are common in sleep apnea. The headaches may be due to disrupted sleep patterns and oxygen deprivation. Excessive daytime sleepiness is a result of poor quality sleep.
Choice A (Narcolepsy) is incorrect because narcolepsy is characterized by sudden, uncontrollable episodes of falling asleep during the day, often accompanied by cataplexy and sleep paralysis, which are not mentioned in the scenario.
Choice B (Parasomnia) is incorrect because parasomnias involve abnormal behaviors during sleep, such as sleepwalking or night terrors, which are not described in the scenario.
Choice D (None of the above) is incorrect because the symptoms described align with obstructive sleep apnea.
A client tells the nurse he has just finished an important business meeting, when in fact he has been napping. Upon what rationale should the nurse's response be based?
- A. Ignoring memory deficit avoids catastrophic reactions.
- B. Delusions should be confronted to clarify thinking.
- C. Reality should be reinforced to maximize functioning.
- D. Changing the topic provides diversion.
Correct Answer: C
Rationale: The correct answer is C because reinforcing reality helps the client maintain maximum functioning. By gently guiding the client back to reality, the nurse can support their cognitive abilities and prevent further confusion or disorientation. Choice A is incorrect because ignoring memory deficits does not address the issue at hand. Choice B is incorrect as confronting delusions may lead to increased distress. Choice D is incorrect as it does not address the situation effectively and may not help the client maintain cognitive functioning.