Nokea
In activity 5, all of the following people got sick from the concession stand except
- A. Jose
- B. Lisa
- C. Mia
- D. Ken
Correct Answer: D
Rationale: Assuming Ken did not get sick (context-specific), he is the exception among those listed.
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A client seen by the rape crisis nurse 1 month after the incident states, 'I'm confused and just not myself. I have mood swings during the day, and I have nightmares at night. Sometimes I think I'm going crazy.' Other times, she is just plain afraid to be alone. The nurse should assess the client for:
- A. Trauma syndrome.
- B. Post-traumatic stress disorder.
- C. Acute stress disorder.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Trauma syndrome. This choice is correct because the client's symptoms of confusion, mood swings, nightmares, feeling like they are going crazy, and fear of being alone align with the criteria for trauma syndrome. This syndrome encompasses a range of symptoms that occur after experiencing a traumatic event, such as rape.
Choice B: Post-traumatic stress disorder (PTSD) is not the best option in this case because the client's symptoms are more indicative of acute distress and confusion rather than the criteria for a formal diagnosis of PTSD, which typically requires the persistence of symptoms over time.
Choice C: Acute stress disorder is also not the most appropriate choice because while some symptoms may align, the duration and specific criteria for this disorder may not fully match the client's presentation.
Choice D: None of the above is incorrect as trauma syndrome best fits the client's symptoms based on the information provided.
A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to my husband, since he continues to abuse me.' The nurse is aware that the final decision to leave a batterer:
- A. Often occurs after the victim suffers a serious injury
- B. Is usually a gradual process that occurs over time
- C. Is more likely if the client has approval from the church
- D. Is made with the batterer's permission
Correct Answer: B
Rationale: The correct answer is B: Is usually a gradual process that occurs over time.
Rationale:
1. Leaving an abusive partner is a complex and difficult decision that often requires careful planning and support.
2. Victims may face various barriers such as financial dependence, emotional attachment, and fear of further violence.
3. It is rare for victims to abruptly leave without considering their safety and well-being.
4. The statement 'I probably should not keep going back' indicates a gradual realization and contemplation of leaving.
Summary:
A: The decision to leave is not solely based on serious injury; victims may leave before any significant harm occurs.
C: Approval from the church may influence the victim's decision but is not a determining factor.
D: Leaving an abusive partner should not require the batterer's permission; it is a personal choice made by the victim.
Which of the following statements by a patient with anorexia nervosa indicates a need for further education?
- A. I want to gain weight, but only if I can stay under 120 pounds.
- B. I understand that my body weight is dangerously low.
- C. I know that food is the enemy and I need to avoid it at all costs.
- D. I am willing to work with my healthcare team to improve my nutrition.
Correct Answer: C
Rationale: The correct answer is C because it indicates a misunderstanding of anorexia nervosa. Patients with anorexia often see food as the enemy, which is a distorted perception. Understanding that food is necessary for nourishment and health is crucial in recovery. Choice A shows an unhealthy weight goal, choice B shows awareness of low weight, and choice D shows willingness to work with the healthcare team, all of which are positive signs.
What is the primary nursing concern for a patient with anorexia nervosa during the early stages of treatment?
- A. Ensuring rapid weight gain to restore health.
- B. Addressing the patient's psychological issues related to body image.
- C. Maintaining nutritional intake to prevent further weight loss.
- D. Promoting self-esteem and body image satisfaction.
Correct Answer: C
Rationale: The primary nursing concern for a patient with anorexia nervosa in the early stages of treatment is maintaining nutritional intake to prevent further weight loss. This is crucial as malnutrition can lead to serious health complications. Ensuring adequate nutrition supports physical health and provides a foundation for addressing psychological issues in later stages of treatment. Rapid weight gain (A) can be harmful and lead to refeeding syndrome. Addressing psychological issues (B) and promoting self-esteem (D) are important but secondary concerns once nutritional stability is achieved.
An acutely psychotic individual diagnosed with schizophreniaform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions?
- A. Day of admission
- B. Day 3 of hospitalization
- C. Day 5 of hospitalization
- D. Day 7 of hospitalization
Correct Answer: B
Rationale: The correct answer is B: Day 3 of hospitalization. At this point, the risperidone medication would have had sufficient time to begin exerting its therapeutic effects on the individual's symptoms of hallucinations and delusions. It typically takes a few days for antipsychotic medications like risperidone to reach therapeutic levels in the body and start alleviating psychotic symptoms. By day 3, the individual may start to demonstrate improved trust in the nurse due to the reduction in distressing symptoms.
Incorrect options:
A: Day of admission - It is unlikely to see significant improvement in symptoms and trust on the same day of admission.
C: Day 5 of hospitalization - By this time, the medication would have likely already started showing some effects, and the individual would have had some time to build trust with the nurse.
D: Day 7 of hospitalization - Waiting until day 7 might be too late to note beginning trust and significant reduction in symptoms, as the