Nokea
An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?
- A. Reinforce the need for the adolescent to attend group therapy sessions
- B. Tell the mother to describe her feelings of helplessness to her child
- C. Advise the mother to call the police if violent behavior occurs again
- D. Refer the mother for psychiatric evaluation for anxiety and depression
Correct Answer: C
Rationale: Advising the mother to call the police if violent behavior recurs prioritizes safety for the adolescent and household. Therapy attendance is important but secondary to immediate safety. Discussing the mother's feelings or referring her for evaluation does not address the acute risk.
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Which reason(s) should the nurse expect a female client to use when she is having difficulty leaving a relationship where she is a victim of intimate partner violence? Select all that apply.
- A. Shame and guilt
- B. Children
- C. Religious beliefs about marriage
- D. The perpetrator will not change
- E. Financial dependency
Correct Answer: A,B,C,E
Rationale: A: Shame and guilt can prevent leaving due to fear of judgment. B: Children influence staying for their well-being or custody concerns. C: Religious beliefs about marriage may emphasize staying. E: Financial dependency is a common barrier. D: Belief the perpetrator won't change is not a reason to stay but rather a reason to leave.
Nurses' Notes
• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. The statement by the client represents and should be followed up with an
- A. suicidal ideation, assessment of risk factors for suicide
Correct Answer: A
Rationale: The client's statement reflects suicidal ideation, requiring immediate assessment of suicide risk factors (e.g., history, stressors, support systems) to determine appropriate interventions, ranging from monitoring to psychiatric evaluation.
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?
- A. Share personal values to put the client at ease
- B. Ask questions in a vague, non-specific format
- C. Begin with questions that are less sensitive in nature
- D. Get the most difficult questions over with first
Correct Answer: C
Rationale: Beginning with less sensitive questions allows the client to gradually build trust and rapport with the nurse before addressing more sensitive topics like suicidal ideation. Sharing personal values may blur professional boundaries. Vague questions may not yield accurate information. Starting with difficult questions may overwhelm the client and hinder trust.
A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?
- A. Folic Acid
- B. Haloperidol
- C. Trazodone
- D. Vitamin B1
Correct Answer: D
Rationale: Vitamin B1 (thiamine) is crucial in alcohol detoxification to prevent Wernicke's encephalopathy and Korsakoff's syndrome due to thiamine deficiency. Folic acid is beneficial but not immediate. Haloperidol and trazodone are not indicated for detoxification.
What symptoms are consistent with long-term rape trauma? Select all that apply.
- A. Social withdrawal
- B. Exaggerated startle response
- C. Intrusive thoughts
- D. Avoidance of places associated with the assault
Correct Answer: A,B,C,D
Rationale: A: Social withdrawal reflects ongoing distress. B: Exaggerated startle response persists post-trauma. C: Intrusive thoughts are unwanted trauma-related memories. D: Avoidance of trauma-associated places is a protective mechanism. All are hallmark long-term symptoms of rape-trauma syndrome.