Nokea
An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply.
- A. Body map.
- B. DNA swabs.
- C. Photographs.
- D. Pulse oximeter.
Correct Answer: A
Rationale: The correct answer is A: Body map. In cases of sexual assault, a body map is essential to document and track injuries and evidence. It helps in accurately recording the location and nature of injuries on the victim's body. DNA swabs and photographs are also important for collecting forensic evidence. DNA swabs can help in identifying the perpetrator, while photographs can visually document injuries and evidence. However, a pulse oximeter is not typically needed for collecting forensic evidence in cases of sexual assault. It is used to measure oxygen saturation in the blood and is not directly relevant to documenting forensic evidence in this context.
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Vascular dementia is more common in individuals living in:
- A. The United States
- B. Japan
- C. France
- D. Australia
Correct Answer: B
Rationale: The correct answer is B: Japan. Vascular dementia is more common in countries with a high prevalence of risk factors such as hypertension, diabetes, and cardiovascular diseases. Japan has a high prevalence of these risk factors due to lifestyle factors and aging population. The other choices (A, C, D) do not have the same level of risk factors or population demographics as Japan, making them less likely to have a higher incidence of vascular dementia.
People who experience psychotic disorders lose:
- A. The will to continue
- B. Contact with reality
- C. The ability to comply with treatment
- D. Contact with intellectual functions
Correct Answer: B
Rationale: Certainly! The correct answer is B: People who experience psychotic disorders lose contact with reality. Psychotic disorders involve a disconnection from reality, leading to hallucinations, delusions, and impaired thinking. This loss of contact with reality is a hallmark of psychotic disorders.
As for the other choices:
A: The will to continue - While individuals with psychotic disorders may struggle with motivation, this is not the primary feature of psychotic disorders.
C: The ability to comply with treatment - While compliance with treatment may be challenging, it is not the core aspect of psychotic disorders.
D: Contact with intellectual functions - While psychotic disorders can impact cognitive abilities, the defining characteristic is the loss of contact with reality rather than intellectual functions.
A patient has a maladaptive response to eating regulation. Findings include the following: height, 5 feet 3 inches; current weight, 80 pounds with weight loss of 30% of body weight over the past 3 months; T, 96.6m F; BP, 68/40; P, 40; R, 20; poor skin turgor; lanugo; amenorrhea of 6 months' duration; admits to restricting intake to 350 calories daily; is a vegetarian; dissatisfied with eating pattern as evidenced by patient statement, 'I need to lose another 10 pounds to be at ideal weight'; diagnostic testing reveals serum potassium of 2.9 mEq/L and urine specific gravity of 1.028. Which of the following would be the highest priority nursing diagnosis for this patient?
- A. Imbalanced nutrition, less than body requirements.
- B. Disturbed body image.
- C. Deficient fluid volume.
- D. Powerlessness.
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume. The patient is displaying signs of severe malnutrition and dehydration, as evidenced by significant weight loss, low blood pressure, low heart rate, and poor skin turgor. The low serum potassium and high urine specific gravity indicate dehydration. Addressing fluid volume deficiency is the top priority to stabilize the patient's condition and prevent further complications like electrolyte imbalances and organ damage. Choices A and B are important but secondary to addressing the immediate threat of dehydration. Choice D is not the priority as the patient's primary concern is physiological rather than psychological.
A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after experiencing an event in which self-esteem is challenged. The most recent episodes of violence were related to feeling 'upset' over a job loss. What type of therapy would provide the greatest help to the victim?
- A. Individual therapy
- B. Group therapy
- C. Couples therapy
- D. Family therapy
Correct Answer: A
Rationale: The correct answer is A: Individual therapy. In this scenario, individual therapy would be most beneficial because it allows the victim to focus on healing and developing coping strategies for dealing with the abuse and rebuilding self-esteem. Addressing the victim's psychological well-being and empowering them to recognize and address the abusive behavior is crucial. Group therapy (B) may not provide the necessary individualized support. Couples therapy (C) could potentially put the victim at further risk of harm. Family therapy (D) may not address the specific dynamics of the abusive relationship.
A patient with an eating disorder states, 'I heard people laughing behind me in the check-out line at the department store. I bet they thought it was hysterically funny that I gained a pound in the last few days.' The nurse documents that the patient is exhibiting which cognitive distortion related to maladaptive eating regulation responses?
- A. Magnification
- B. Personalization
- C. Overgeneralization
- D. Dichotomous thinking
Correct Answer: B
Rationale: The correct answer is B: Personalization. Personalization is a cognitive distortion where an individual attributes external events to themselves without any evidence. In this case, the patient is assuming that people laughing were directed at them and related to their weight gain, which is a distorted belief.
A: Magnification involves blowing things out of proportion, which is not evident in this scenario.
C: Overgeneralization involves drawing broad conclusions based on a single incident, which is not happening here.
D: Dichotomous thinking involves seeing things in black and white terms, which is not demonstrated in the patient's statement.
In summary, the patient's attribution of others' laughter to their weight gain without evidence aligns with the cognitive distortion of personalization, making it the correct choice.