Nokea
An advance directive gives legally binding direction for health care interventions when a patient:
- A. has a new diagnosis of cancer
- B. is diagnosed with Parkinsons disease
- C. is unable to make decisions for self because of illness
- D. diagnosed with amyotrophic lateral sclerosis is unable to speak
Correct Answer: C
Rationale: Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinsons disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.
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The nursing diagnosis Rape-trauma syndrome is established for a rape victim in the emergency department. Select the most important outcome to achieve before discharging the patient!
- A. The patient will describe feelings of safety and relaxation.
- B. The memory of the rape will be less vivid and less frightening.
- C. Physical symptoms of pain and discomfort are no longer present.
- D. The patient will agree to keep a follow-up appointment with a rape victim advocate.
Correct Answer: D
Rationale: The correct answer is D. Establishing a follow-up appointment with a rape victim advocate is crucial for ongoing support and recovery. It ensures the patient has access to necessary resources and assistance in coping with the trauma. Choice A focuses on emotional well-being but doesn't address long-term support. Choice B addresses memory but doesn't ensure ongoing care. Choice C only addresses physical symptoms, neglecting the emotional and psychological impact of the trauma. Thus, choice D is the most important outcome to achieve before discharging the patient to promote comprehensive care and support.
A patient with fluctuating levels of awareness, confusion, and disorientation shouts, 'The bugs, they are crawling on my legs! Get them off me!' The nurse's inspections show that no bugs are present. The nurse can best assess this presentation as:
- A. Perseveration.
- B. Hypermetamorphosis.
- C. Tactile hallucinations.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Tactile hallucinations. Tactile hallucinations involve the perception of physical sensations such as bugs crawling on the skin when no external stimuli are present. In this scenario, the patient's complaint of bugs crawling on their legs despite the nurse's inspection confirming the absence of bugs indicates a sensory hallucination, specifically a tactile one. This is different from perseveration (repetition of a particular response or activity) and hypermetamorphosis (excessive attention to environmental details). Choosing "None of the above" would not address the specific symptom of tactile hallucinations described in the patient's presentation.
In planning aftercare for a client with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the client to have stimulation, structure, socialization, and support. Which option would best incorporate these factors?
- A. Day hospitalization
- B. Attending a psychosocial club
- C. Living with his elderly mother
- D. Spending free time in the mall
Correct Answer: B
Rationale: The correct answer is B, attending a psychosocial club. This option best incorporates the factors of stimulation, structure, socialization, and support. Psychosocial clubs offer a structured environment with various activities to stimulate the client's mind and prevent social isolation. It provides opportunities for socialization and peer support, which are crucial for individuals with schizophrenia. Day hospitalization may offer structure but lacks the socialization aspect. Living with his elderly mother may provide support but not necessarily the stimulation and structure needed. Spending free time in the mall does not provide the structured environment, socialization, or support necessary for aftercare in schizophrenia.
A patient diagnosed with schizophrenia approaches the nurse and says, 'Cats eat birds. East now. Job is new. You father.' This speech pattern can be assessed as:
- A. hyperverbosity.
- B. circumstantiality.
- C. loose associations.
- D. expressing delusions.
Correct Answer: C
Rationale: The correct answer is C: loose associations. This speech pattern is characteristic of loose associations seen in schizophrenia, where thoughts are disorganized and lack logical connections. The patient's statements lack coherence and jump from one topic to another without a clear link. Hyperverbosity (A) refers to excessive speech without a clear point, which is not evident in this scenario. Circumstantiality (B) involves excessive detail before reaching the main point, which is not present here. Expressing delusions (D) would involve holding false beliefs, which are not explicitly stated in the patient's speech.
A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to my husband, since he continues to abuse me.' The nurse is aware that the final decision to leave a batterer:
- A. Often occurs after the victim suffers a serious injury
- B. Is usually a gradual process that occurs over time
- C. Is more likely if the client has approval from the church
- D. Is made with the batterer's permission
Correct Answer: B
Rationale: The correct answer is B: Is usually a gradual process that occurs over time.
Rationale:
1. Leaving an abusive partner is a complex and difficult decision that often requires careful planning and support.
2. Victims may face various barriers such as financial dependence, emotional attachment, and fear of further violence.
3. It is rare for victims to abruptly leave without considering their safety and well-being.
4. The statement 'I probably should not keep going back' indicates a gradual realization and contemplation of leaving.
Summary:
A: The decision to leave is not solely based on serious injury; victims may leave before any significant harm occurs.
C: Approval from the church may influence the victim's decision but is not a determining factor.
D: Leaving an abusive partner should not require the batterer's permission; it is a personal choice made by the victim.