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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 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.
An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which indicator would suggest that nursing interventions are succeeding?
- A. The child attends school regularly.
- B. The child is observed playing calmly.
- C. The father rarely speaks during nurse visits.
- D. The mother corrects negative comments by the child.
Correct Answer: A
Rationale: The correct answer is A because regular school attendance indicates the child's improved well-being and ability to prioritize education over caregiving responsibilities.
B: Playing calmly does not necessarily indicate overall improvement in the child's situation.
C: The father's silence during nurse visits does not directly reflect the child's well-being or progress.
D: The mother correcting negative comments by the child is positive but does not directly address the child's caregiving responsibilities or self-perceptions.
The severe feeling of restlessness produced by some psychotropic medications, which is often misinterpreted by patients as anxiety or a recurrence of psychiatric symptoms, is known as:
- A. akathisia
- B. akinesia
- C. bradykinesia
- D. dystonia
Correct Answer: A
Rationale: Akathisia is a common side effect of antipsychotics, characterized by restlessness often mistaken for worsening psychiatric symptoms.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. Appropriately express angry feelings.
- B. Verbalize two positive things about self.
- C. Verbalize the importance of eating a balanced diet.
- D. None of the above.
Correct Answer: D
Rationale: Rationale:
1. Patient's diagnosis indicates coping issues, not anger expression or self-esteem.
2. Patient's coping mechanism involves overeating and vomiting, not diet.
3. Outcome should focus on coping skills improvement, not unrelated goals.
4. None of the choices address the root issue of coping with loneliness and isolation.
5. Thus, the correct answer is D, as none of the options directly address the patient's ineffective coping mechanism.
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.