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A woman has been severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, has no financial resources of her own, and has no job skills. Which would be the most important referral for the nurse to make?
- A. Community food cupboard
- B. Vocational counseling
- C. Law enforcement
- D. Safe house or shelter
Correct Answer: D
Rationale: The correct answer is D: Safe house or shelter. This option is the most important referral because the woman is in immediate danger and needs a safe place to stay away from her abusive husband. It prioritizes her safety and well-being. Referring her to a safe house can provide her with protection, resources, and support to help her escape the abusive situation.
Choice A (Community food cupboard) is incorrect as it does not address the woman's immediate safety needs. Choice B (Vocational counseling) is also not the most urgent referral in this situation as the woman's safety should be the priority. Choice C (Law enforcement) might be necessary in the long run, but the immediate concern is ensuring the woman's safety by referring her to a safe house or shelter.
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A client with obsessive-compulsive personality disorder is described by other staff as being perfectionistic, inflexible, and a 'master at procrastination.' The nurse learns that the client is nearly immobilized during times that call for the client to make a decision. The nurse realizes that the most likely hypothesis is this behavior is related to:
- A. A need to make others uncomfortable
- B. Needing to be the center of attention
- C. Wanting someone else to be responsible
- D. Fear of making a mistake
Correct Answer: D
Rationale: The correct answer is D: Fear of making a mistake. This is because individuals with obsessive-compulsive personality disorder often have an intense fear of making errors or mistakes. This fear can lead to indecisiveness and procrastination when faced with decision-making tasks. The client's behavior of being nearly immobilized during times requiring decision-making is characteristic of this fear of making a mistake.
Incorrect choices:
A: A need to make others uncomfortable - This is not related to the fear of making a mistake commonly seen in individuals with obsessive-compulsive personality disorder.
B: Needing to be the center of attention - This is not a typical characteristic of individuals with obsessive-compulsive personality disorder.
C: Wanting someone else to be responsible - This is not directly related to the fear of making a mistake, which is a core feature of the disorder.
Which disorder is associated with persons with a body weight that is normal or even slightly above average?
- A. Pica.
- B. Bulimia.
- C. Obesity.
- D. Anorexia nervosa.
Correct Answer: B
Rationale: The correct answer is B: Bulimia. Individuals with bulimia nervosa typically have a normal or slightly above average body weight due to the cycle of binge eating and purging behaviors. This is because they consume large amounts of food during binges but then engage in compensatory behaviors such as vomiting or excessive exercise to prevent weight gain. In contrast, choices A (Pica) and D (Anorexia nervosa) are associated with low body weight. Choice C (Obesity) is characterized by excess body weight. Bulimia is the only disorder in the list where individuals can have a normal or slightly above average body weight due to the nature of their eating behaviors.
A nurse assesses that which of the following individuals is most likely to engage in eating behaviors characteristic of bulimia?
- A. A person who weighs 225 pounds and is 5 feet 4 inches tall.
- B. A person who is 5 pounds overweight and cannot stick to a diet.
- C. A person who lost up to 40 pounds but gained it back within 1 year.
- D. None of the above.
Correct Answer: A
Rationale: Step 1: Individuals with bulimia often engage in episodes of binge eating followed by purging behaviors.
Step 2: Choice A, a person who is significantly overweight, is more likely to engage in binge eating behavior.
Step 3: Being overweight can be a risk factor for bulimia due to body image concerns.
Step 4: Choices B and C do not provide as strong indicators for bulimia as choice A.
Summary: Choice A is correct as being significantly overweight is a common characteristic of individuals with bulimia. Choices B and C lack the same level of risk factors for engaging in eating behaviors characteristic of bulimia.
A patient with schizophrenia tells the nurse 'I don't know, it's just all the same. You never know. It comes, it goes, it blows away. Get it?' The best response for the nurse to make would be:
- A. Nothing you are saying is clear; you are not making sense.'
- B. Yes, life can be like that sometimes, very confusing.'
- C. Try to organize your thoughts and then tell me again.'
- D. I am having difficulty understanding what you are saying.'
Correct Answer: D
Rationale: The correct answer is D because it reflects active listening and acknowledges the patient's communication difficulties without being dismissive. By stating difficulty in understanding, the nurse shows empathy and openness to further clarification. Choice A is incorrect as it may be perceived as judgmental. Choice B is incorrect as it does not address the patient's communication challenges. Choice C is incorrect as it places the responsibility solely on the patient without offering support.
The nurse is to perform a complete assessment of a client in her home, using the Mini-Mental State Examination as one component. When the nurse arrives, the client is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The client's husband says, 'Let's get on with this business.' The client is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be to:
- A. Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room
- B. Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled
- C. Not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family
- D. Ask the husband to make an appointment to bring his wife to the clinic for testing
Correct Answer: B
Rationale: The correct answer is B because conducting a Mini-Mental State Examination (MMSE) in a distracting environment with the client exhibiting signs of distress would likely yield inaccurate results. By explaining the importance of the testing process and rescheduling for a quieter day, the nurse ensures a more accurate assessment. This allows for a controlled environment conducive to obtaining reliable data.
Choice A is incorrect because simply moving the husband and grandchildren to another room may not eliminate distractions or address the client's distress, potentially still impacting the accuracy of the assessment.
Choice C is incorrect as relying solely on observations and reports from the family may not provide a comprehensive assessment of the client's cognitive function, as the MMSE is a standardized tool designed for objective evaluation.
Choice D is incorrect as it does not address the immediate issue of conducting the assessment in a more suitable environment and may disrupt the client's routine by requiring a clinic visit.