Nokea
The nurse continues to care for the patient
The client is a 19-year-old male who is in the emergency room for a leg injury. He states he was returning to his dorm from a party and fell about 5 feet (1.5 meters) into a small ravine on campus. The client states that he drinks socially and takes no medications for any health condition.
The nurse is listening to the client.
Because the client is a male, he is especially at risk for which psychosocial two sequalae of sexual assault?
- A. Suicide
- B. Depression
- C. Post-traumatic stress disorder
- D. Becoming an abuser
- E. Human immunodeficiency virus
- F. Chlamydia
Correct Answer: B,C
Rationale: B: Depression is common post-sexual assault due to psychological trauma. C: PTSD is frequent, with symptoms like flashbacks and anxiety. A: Suicide is a risk but not male-specific. D: Becoming an abuser is less common. E, F: HIV and chlamydia are physical, not psychosocial, risks.
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History and physical
The client is a 19-year-old male who is in the emergency room for a leg injury. He states he was returning to his dorm from a party and fell about 5 feet (1.5 meters) into a small ravine on campus.
The client states that he drinks socially and takes no medications for any health condition
In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.
- A. Wait until the client is completely calm
- B. Ask difficult questions first to get them out of the way
- C. Use silence as a tool
- D. Speak with the client in private
- E. Observe nonverbal behavior and react accordingly
- F. Ask several questions in a row
Correct Answer: A,C,D,E
Rationale: A: Waiting until the client is calm fosters a safe environment. C: Silence allows the client time to process thoughts. D: Privacy ensures confidentiality and comfort. E: Observing nonverbal behavior provides emotional cues. B: Difficult questions first may increase anxiety. F: Multiple questions can overwhelm the client.
A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?
- A. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol
- B. Take the medication with at least 8 ounces (240 mL) of water and limit alcohol consumption while taking this medication
- C. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol
- D. Take the medication each morning beginning 48 hours after your last drink of alcohol
Correct Answer: D
Rationale: Disulfiram must be started at least 48 hours after the last alcohol intake to prevent severe reactions, and alcohol must be completely avoided. Options A and B incorrectly suggest limited alcohol is safe. Option C risks reactions if alcohol is still in the system.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A middle-aged man who is complaining of shortness of breath and is diaphoretic
- B. A young woman who suddenly goes blind with no indication of organic pathology
- C. An older adult who continuously complains of a headache and back pain
- D. An adolescent who becomes extremely anxious about going outside
Correct Answer: B
Rationale: Sudden blindness with no organic pathology suggests a functional neurological symptom disorder, which falls under conversion disorder. Shortness of breath and diaphoresis may indicate a medical condition or panic attack. Headaches and back pain could have various causes. Anxiety about going outside suggests agoraphobia or another anxiety disorder.
Which individual should the nurse consider at highest risk for suicide?
- A. A retired older male whose significant other has passed away
- B. A nurse who works in a pediatric emergency department
- C. An adolescent male whose parents recently divorced
- D. A single working mother with three pre-school aged children
Correct Answer: C
Rationale: Adolescents experiencing significant life changes like parental divorce are at increased suicide risk due to emotional upheaval and limited coping skills. Older males may have coping mechanisms. Stressful jobs or parenting are less specific risk factors without additional context.
An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?
- A. Reinforce the need for the adolescent to attend group therapy sessions
- B. Tell the mother to describe her feelings of helplessness to her child
- C. Advise the mother to call the police if violent behavior occurs again
- D. Refer the mother for psychiatric evaluation for anxiety and depression
Correct Answer: C
Rationale: Advising the mother to call the police if violent behavior recurs prioritizes safety for the adolescent and household. Therapy attendance is important but secondary to immediate safety. Discussing the mother's feelings or referring her for evaluation does not address the acute risk.