Nokea
A woman whose husband physically abuses her mentions to the nurse, 'Someday I'll have to leave him.' Which of the following would be the nurse's best response?
- A. Yes, you should, before he harms you badly.'
- B. Could we talk about developing a safety plan?'
- C. Are you afraid of what your family will say?'
- D. I don't know why you would stay with him.'
Correct Answer: B
Rationale: The correct answer is B: "Could we talk about developing a safety plan?" This response is the best choice as it acknowledges the woman's situation, offers support, and focuses on practical steps to ensure her safety. By suggesting a safety plan, the nurse is addressing the immediate concern of potential harm and empowering the woman to take control of her situation.
Incorrect Choices:
A: This response is too direct and may not take into account the complexities of the woman's situation. It lacks empathy and does not offer a constructive solution.
C: This response shifts the focus away from the woman's safety and onto external factors. It may come across as judgmental and unhelpful.
D: This response is dismissive and fails to acknowledge the seriousness of the situation. It does not offer any support or guidance to the woman in need.
You may also like to solve these questions
Disability is:
- A. More common in low-income region of the world
- B. Found in 16% or 1.3 billion people worldwide
- C. More common in males
- D. Not inclusive of mental health conditions
Correct Answer: B
Rationale: WHO estimates disability affects 16% of the global population (1.3 billion), including mental health conditions.
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The family cares for her during the evening and at night. Noting the patient had several bruises, the nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage because she is confused and wanders all night. She says the bruises resulted from a fall down stairs. The daughter states, "I have lost my mother, and I cannot bear it anymore. It is wrecking my family."Â The nursing intervention that should take priority is:
- A. Teaching the daughter more about the effects of Alzheimer's disease.
- B. Identifying two options for caregiver respite and care assistance at night.
- C. Supporting the daughter to grieve the loss of her mother's ability to function.
- D. Teaching the family how to give physical care more effectively and efficiently.
Correct Answer: B
Rationale: The correct answer is B: Identifying two options for caregiver respite and care assistance at night. This is the priority intervention because it addresses the immediate need to ensure the patient's safety and well-being while also supporting the daughter who is struggling to cope. By identifying options for caregiver respite and care assistance at night, the daughter can get the help she needs to manage her mother's care effectively without feeling overwhelmed. This intervention promotes both the patient's safety and the daughter's mental well-being.
Choices A, C, and D are incorrect:
A: Teaching the daughter more about the effects of Alzheimer's disease. While education is important, in this scenario, the immediate need is to address caregiver respite and care assistance.
C: Supporting the daughter to grieve the loss of her mother's ability to function. While supporting the daughter emotionally is important, ensuring the patient's safety should take priority.
D: Teaching the family how to give physical care more effectively and efficiently. While this is important
A nurse is caring for a patient with bulimia nervosa. What is the most important aspect of the treatment plan?
- A. To encourage purging behaviors to eliminate binge episodes.
- B. To provide a structured meal plan and monitor food intake.
- C. To focus solely on achieving weight loss.
- D. To offer therapy focused on body image without addressing eating behaviors.
Correct Answer: B
Rationale: The correct answer is B: To provide a structured meal plan and monitor food intake. This is crucial in the treatment of bulimia nervosa as it helps establish regular eating patterns, prevent binge episodes, and promote healthy nutrition. Providing structure and monitoring food intake also helps in addressing underlying psychological issues related to disordered eating. Encouraging purging behaviors (choice A) can worsen the condition and lead to serious health complications. Focusing solely on weight loss (choice C) may reinforce unhealthy behaviors and neglect the holistic approach needed for recovery. Offering therapy focused only on body image (choice D) overlooks the critical component of addressing eating behaviors and nutritional needs.
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse identifies which of the following nursing diagnosis for the client?
- A. Disturbed thought processes
- B. Powerlessness
- C. Ineffective coping
- D. Defensive coping
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This nursing diagnosis is appropriate because the client's symptoms suggest cognitive impairment and delusions, which are common in dementia. The client's accusations of theft and imprisonment indicate a distortion in reality perception, reflecting disturbed thought processes. Powerlessness (B) relates more to lack of control over circumstances, not cognitive issues. Ineffective coping (C) and Defensive coping (D) focus on emotional responses rather than cognitive impairment.
The client tells the nurse, 'I thought my psychiatrist was the best doctor in the world. I thought he understood me completely. Now, I hate him! He doesn't understand me at all. He's just dumping me to go on a 2-week vacation.' The nurse assesses the client's description of feelings about the physician as evidence of the use of:
- A. Splitting
- B. Projective identification
- C. Isolation of affect
- D. Dissociation
Correct Answer: A
Rationale: The correct answer is A: Splitting. Splitting is a defense mechanism where a person sees things in extremes of either all good or all bad. In this scenario, the client initially idealizes the psychiatrist as the best doctor, then suddenly devalues and hates him for taking a vacation, indicating a shift from all good to all bad. This extreme change in perception is characteristic of splitting.
B: Projective identification involves projecting one's own feelings onto another person and then identifying with those projected feelings. This choice does not fit the scenario as the client is not projecting their feelings onto the psychiatrist.
C: Isolation of affect refers to the separation of feelings from ideas and events. The client's strong emotions towards the psychiatrist do not demonstrate a lack of emotional expression or detachment from feelings.
D: Dissociation is a defense mechanism where thoughts, feelings, and experiences are separated from conscious awareness. The client's reaction does not suggest a disconnection from reality or consciousness.