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An older client is brought to the emergency department by a family member with whom the client lives. The nurse observes that the client has poor hygiene, contractures, and pressure ulcers on the sacrum, the scapula, and the heels. Based on the nurse's assessment data, the client is suspected of which form of victimization?
- A. Sexual abuse
- B. Physical abuse
- C. Emotional abuse
- D. Psychological abuse
Correct Answer: B
Rationale: Victimization in a family can take many forms. When analyzing a specific client situation, it is important to understand which form of abuse is being considered. Physical abuse can take the form of battering (hitting, slapping, striking), or it can be more subtle, such as neglect (the failure to meet basic needs). Sexual abuse can involve unwanted sexual remarks, sexual advances, and physical sexual acts. Emotional and psychological abuse can involve inflicting verbal statements that cause mental anguish or alienation of the victim.
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The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, 'Look at all the rescue trucks. It's like watching a movie.' Which defense mechanism does the nurse identify that the client is using?
- A. Dissociation.
- B. Regression.
- C. Projection.
- D. Denial.
Correct Answer: A
Rationale: Dissociation involves detaching from reality to cope with trauma, as seen in the client’s detached, movie-like perception of the accident. Regression, projection, and denial involve different coping mechanisms not reflected in this statement.
The significant other of a client diagnosed with Graves' disease expresses concern regarding the client's bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client?
- A. Grief
- B. Socialization issues
- C. Issues related to sensory perception
- D. Trouble with coping with a disease process
Correct Answer: D
Rationale: A client with Graves' disease may become irritable, nervous, or depressed. The signs and symptoms in the question support option 4. The information in the question does not support the remaining options.
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
- A. residual schizophrenia
- B. paranoid schizophrenia
- C. catatonic schizophrenia
- D. disorganized schizophrenia
- E. undifferentiated schizophrenia
Correct Answer: D
Rationale: Disorganized schizophrenia is characterized by inappropriate affect, social withdrawal, grimacing, and impaired daily functioning.
The nurse provides care for a client diagnosed with bulimia. Which nursing action is most helpful in determining what precipitates the client'sEating disorder?
- A. Observe the family communication patterns at a monitored mealtime.
- B. Distract the client at mealtimes.
- C. Assign the client a food/feelings/thoughts action journal.
- D. Ask the client to write a history of eating behaviors.
Correct Answer: C
Rationale: A food/feelings/thoughts journal helps identify triggers and patterns associated with binge-purge behaviors, providing insight into precipitants. Observing family dynamics is useful but less direct, and distraction or history-writing are less focused on current triggers.