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An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
- A. The patient's vital signs
- B. Consent signed by the patient
- C. Supervision and credentials of the examiner
- D. Storage location of the patient's personal effects
Correct Answer: B
Rationale: The correct answer is B: Consent signed by the patient. This is crucial as it ensures the patient's autonomy and willingness to undergo evidence collection. Without proper consent, the procedure would be unethical and potentially illegal. Vital signs (A) may be important for overall assessment but are not directly related to evidence collection. Supervision and credentials of the examiner (C) are necessary but not the most important documentation. The storage location of personal effects (D) is relevant for patient safety but not essential for evidence collection.
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A 72-year-old widow has just returned home after 2 weeks in the hospital after a fall. She lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the visiting nurse stopped by 2 days after discharge, he found the woman confused and disoriented, with an unsteady gait. The patient asks him who he is and why he is there. The nurse correctly deduces that the most likely cause for the changes seen in the patient is:
- A. Delirium.
- B. Dementia.
- C. Drug toxicity.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Delirium. The patient's sudden onset of confusion, disorientation, and unsteady gait after discharge from the hospital suggests delirium. Delirium is an acute change in mental status with fluctuating symptoms, often caused by underlying medical conditions, medications (such as diazepam), or environmental factors. In this case, the recent hospitalization, multiple medications, and potential stressors like living alone and recent fall increase the risk for delirium.
Incorrect choices:
B: Dementia is a chronic, progressive condition characterized by memory loss and cognitive decline. The sudden onset of symptoms in this case is not consistent with dementia.
C: Drug toxicity could be a possibility given the patient's medication list, but delirium is a more likely explanation due to the acute onset of symptoms post-hospitalization.
D: None of the above is incorrect because delirium is the most likely cause based on the patient's presentation and risk factors.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.
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.
A 17-year-old client who has anorexia nervosa states she believes she will have fewer problems in college and will be more popular if she continues to lose weight. What nursing intervention would be useful at this time?
- A. Assisting the client to identify the problems causing her concern.
- B. Determining what she hopes to gain from the behavior.
- C. Explaining that her chances for becoming ill from losing weight are high.
- D. Having a physical report sent to college officials indicating her condition.
Correct Answer: A
Rationale: The correct answer is A because it focuses on assisting the client to identify the problems causing her concern. By helping the client explore the underlying issues driving her desire to lose weight, the nurse can address the root cause of her behavior. This intervention promotes self-awareness and insight, enabling the client to better understand her motivations and make informed choices.
Option B is incorrect because while determining what the client hopes to gain from the behavior is important, it does not directly address the immediate concern of identifying underlying problems.
Option C is incorrect because simply explaining the risks of becoming ill may not effectively address the client's belief that losing weight will lead to fewer problems and increased popularity.
Option D is incorrect because sending a physical report to college officials without the client's consent may violate confidentiality and trust, and it does not address the client's psychological needs.
The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. What components should the plan include? Select all that apply.
- A. A code word to signal children that it is time to leave.
- B. Phone numbers for the nearest shelter and crisis hotline.
- C. Telling the spouse that she has a plan and will leave.
- D. Collecting birth certificates and other essential documents.
Correct Answer: A
Rationale: The correct answer is A: A code word to signal children that it is time to leave. This is crucial for ensuring the safety of the victim and their children without alerting the abuser. Other choices like B, providing phone numbers for shelters, are important but may not always be feasible in an emergency. Choice C, informing the spouse about the plan, can escalate the situation. Choice D, collecting essential documents, is important but may not always be the immediate priority in a dangerous situation. Having a code word ensures a discreet and quick escape if needed.