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After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
- A. Victims of domestic violence are often the best predictors of their risk of harm.
- B. Victims of domestic violence often overestimate their safety risk.
- C. Victims of domestic violence are typically in a state of denial.
- D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct Answer: A
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. It is crucial for the nurse to ensure that the client is expressing herself authentically and not downplaying any potential danger. While victims can be insightful about their risk, it's essential to involve proper authorities, such as the police, in situations of intimate partner violence to ensure safety and provide necessary support. Choice B is incorrect because victims may not necessarily overestimate their safety risk. Choice C is incorrect as not all victims are in a state of denial; some may recognize the dangers they face. Choice D is incorrect because victims may not believe that keeping peace with their partner is the best way to prevent future attacks, as each individual's situation and mindset vary.
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How does the ANA define the psychiatric nursing role?
- A. a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art
- B. assisting the therapist to relieve the symptoms of clients
- C. to solve clients' problems and give them the answers
- D. having a client committed to long-term therapy with the nurse
Correct Answer: A
Rationale: The correct answer aligns with the ANA's definition of the psychiatric nursing role. According to the ANA, psychiatric nursing is a specialized area of nursing practice that incorporates theories of human behavior as its foundational science and utilizes the self as its essential art. This definition emphasizes the importance of understanding human behavior and leveraging therapeutic communication and relationships to provide effective care for individuals with mental health concerns. Choices B, C, and D are incorrect because they do not accurately represent the ANA-defined role of psychiatric nursing. Psychiatric nurses primarily focus on delivering holistic care, promoting mental health, and supporting individuals with mental health challenges using evidence-based practices and therapeutic interventions.
A client sitting alone and talking to voices is observed by a nurse. When asked, the client reports he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: When a client reports talking to voices, it can indicate the presence of hallucinations. Asking the client to describe what is happening is a crucial step as it helps the nurse understand the nature of the hallucinations and provides reassurance to the client. Touching the client without consent is inappropriate and can be distressing. Leaving the client alone may not address the underlying issue, and telling the client there are no voices denies their experience and can lead to mistrust.
After experiencing a traumatic event like losing a child due to poisoning, a client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The correct answer is C: sociocultural indicator. In this situation, the client's reluctance to make new friends after experiencing a traumatic event like losing a child due to poisoning reflects a change in their social behavior, which is influenced by sociocultural factors. This response indicates how stress can impact a person's relationships and social interactions. Choice A, emotional indicator, is incorrect because the client's statement is more related to social interactions than emotional expression. Choice B, spiritual indicator, is incorrect as the given scenario does not directly involve spiritual beliefs or practices. Choice D, intellectual indicator, is also incorrect as the client's statement does not reflect cognitive or intellectual changes but rather social aspects affected by the stressful event.
The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
- A. The client receiving linear accelerator radiation therapy for lung cancer
- B. The client with a radium implant for cervical cancer
- C. The client who has just been administered soluble brachytherapy for thyroid cancer
- D. The client who returned from placement of iridium seeds for prostate cancer
Correct Answer: A
Rationale: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is the correct choice because the radiation stays in the department, and the client is not radioactive. Choices B, C, and D involve clients who are radioactive or pose a risk due to radioactivity. The client with a radium implant for cervical cancer (choice B) is radioactive, the client who has just been administered soluble brachytherapy for thyroid cancer (choice C) is radioactive for approximately 72 hours, and the client who returned from placement of iridium seeds for prostate cancer (choice D) is also radioactive, especially right after the procedure. These options are not suitable for assignment to the pregnant nurse.
In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's
- A. feelings about what has been described.
- B. thoughts about what has been described.
- C. possible solutions to the problem.
- D. intent in sharing the description.
Correct Answer: B
Rationale: In performing a psychosocial assessment, the nurse follows a structured approach, starting with encouraging the client to describe problematic behaviors and situations. The next step is to elicit the client's thoughts about what has been described. This step helps gather more assessment data and understand how the client interprets the situation. Asking about feelings, exploring possible solutions, and understanding the client's intent in sharing the description are more complex processes that come later in the assessment. Therefore, the correct next step after describing behaviors and situations is to inquire about the client's thoughts.