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A victim of rape says, "My family is not very supportive."Â Which belief contributes to a negative family response?
- A. No one asks to be raped.
- B. Rape is an act of aggression.
- C. Rape should not be discussed.
- D. Anyone is a potential rape victim.
Correct Answer: C
Rationale: The correct answer is C: Rape should not be discussed. This belief contributes to a negative family response because it promotes silence and stigma around the topic of rape, leading to lack of support and understanding for the victim. By not discussing rape, the victim may feel isolated, ashamed, and unable to seek help or share their experience. Choices A and B are incorrect as they acknowledge the victim's innocence and the violent nature of rape. Choice D is incorrect as it recognizes the reality that anyone can be a victim, but it does not directly address the issue of discussing rape within the family.
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The nurse notes that a male client, who is taking an antipsychotic medication, is constantly moving from chair to chair during a group activity, and he complains that he feels 'nervous and jittery inside.' The nurse is aware that this client most likely is experiencing:
- A. Akinesia
- B. Dystonia
- C. Dyskinesia
- D. Akathisia
Correct Answer: D
Rationale: The correct answer is D: Akathisia. Akathisia is a common side effect of antipsychotic medications characterized by restlessness, inability to sit still, and a feeling of inner restlessness or jitteriness. In this case, the client's constant movement and feeling of nervousness align with the symptoms of akathisia.
A: Akinesia is the opposite of what the client is experiencing, characterized by a lack of movement or muscle weakness.
B: Dystonia involves involuntary muscle contractions and abnormal postures, not constant movement.
C: Dyskinesia refers to abnormal, involuntary movements of the face, trunk, and limbs, which are not described in the scenario.
What is an appropriate goal for a nurse working with a patient who has bulimia nervosa?
- A. The patient will engage in daily exercise to control weight.
- B. The patient will eliminate purging behaviors and establish healthy eating habits.
- C. The patient will maintain a low weight and avoid binge episodes.
- D. The patient will adopt a restrictive diet to manage their eating behaviors.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Eliminating purging behaviors addresses the primary symptom of bulimia nervosa.
2. Establishing healthy eating habits promotes long-term recovery and overall well-being.
3. Focusing on behavior change rather than weight control aligns with evidence-based treatment.
4. This goal is client-centered, prioritizing the patient's mental and physical health.
Summary:
A: Focusing solely on exercise does not address the root cause of bulimia.
C: Emphasizing weight maintenance may reinforce unhealthy body image and behaviors.
D: Adopting a restrictive diet can exacerbate disordered eating patterns and harm health.
Which situation would be most likely to serve as a trigger to a catastrophic reaction in a client with stage 2 Alzheimer's disease?
- A. Participating in singing 'Happy Birthday' to another client at dinner
- B. Being scolded by an aide for spilling a glass of milk
- C. Listening to Big Band music from the 1940s
- D. Eating cupcakes in the activities room
Correct Answer: B
Rationale: The correct answer is B because being scolded for spilling milk can trigger feelings of shame, embarrassment, and confusion in a person with Alzheimer's stage 2. This negative interaction can lead to heightened agitation, aggression, or emotional distress due to the client's impaired ability to process and regulate emotions. In contrast, choices A, C, and D involve positive or neutral activities that are less likely to evoke such strong negative emotions or reactions in someone with Alzheimer's disease.
An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply.
- A. Body map.
- B. DNA swabs.
- C. Photographs.
- D. Pulse oximeter.
Correct Answer: A
Rationale: The correct answer is A: Body map. In cases of sexual assault, a body map is essential to document and track injuries and evidence. It helps in accurately recording the location and nature of injuries on the victim's body. DNA swabs and photographs are also important for collecting forensic evidence. DNA swabs can help in identifying the perpetrator, while photographs can visually document injuries and evidence. However, a pulse oximeter is not typically needed for collecting forensic evidence in cases of sexual assault. It is used to measure oxygen saturation in the blood and is not directly relevant to documenting forensic evidence in this context.
Vascular dementia is more common in individuals living in:
- A. The United States
- B. Japan
- C. France
- D. Australia
Correct Answer: B
Rationale: The correct answer is B: Japan. Vascular dementia is more common in countries with a high prevalence of risk factors such as hypertension, diabetes, and cardiovascular diseases. Japan has a high prevalence of these risk factors due to lifestyle factors and aging population. The other choices (A, C, D) do not have the same level of risk factors or population demographics as Japan, making them less likely to have a higher incidence of vascular dementia.