Nokea
The first step in the treatment of incest is to:
- A. believe the child who reports the activity
- B. notify the proper authorities
- C. objectively confront the accused family member
- D. remove the child from the home
Correct Answer: A
Rationale: Believing the child establishes trust and validates their experience, forming the foundation for further protective and therapeutic actions.
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A patient who takes lithium phones the nurse at the clinic to say, "I've had diarrhea for 4 days. I feel weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" Which instruction by the nurse is appropriate?
- A. Have someone bring you to the clinic immediately.
- B. Restrict food and fluids for 24 hours and stay in bed.
- C. Drink a large glass of water with 1 teaspoon of salt added.
- D. Take antidiarrheal medication hourly until the diarrhea subsides.
Correct Answer: A
Rationale: The correct answer is A: Have someone bring you to the clinic immediately. The patient is experiencing symptoms of lithium toxicity, including diarrhea, weakness, unsteadiness, and worsening hand tremor. These symptoms indicate a potential lithium overdose, which can be life-threatening. Bringing the patient to the clinic immediately is crucial for assessment, monitoring, and intervention.
Choice B is incorrect because restricting food and fluids can worsen dehydration and electrolyte imbalances. Choice C is incorrect as adding salt to water can exacerbate electrolyte abnormalities in lithium toxicity. Choice D is incorrect as taking antidiarrheal medication can further worsen the symptoms and delay appropriate medical treatment.
What is the most appropriate nursing goal for a patient with bulimia nervosa?
- A. To eliminate binge-purge episodes and restore healthy eating habits.
- B. To focus on weight loss and body image issues.
- C. To monitor calorie intake and restrict food consumption.
- D. To encourage excessive exercise to maintain weight control.
Correct Answer: A
Rationale: The correct answer is A: To eliminate binge-purge episodes and restore healthy eating habits. This goal is appropriate as it addresses the core issue of bulimia nervosa, which is the cycle of bingeing and purging. By focusing on eliminating these episodes and promoting healthy eating habits, the patient can achieve long-term recovery.
Choices B, C, and D are incorrect because they do not address the underlying psychological and behavioral aspects of bulimia nervosa. Weight loss and body image issues (B) may exacerbate the disorder, monitoring calorie intake and restricting food consumption (C) can reinforce the cycle of bingeing and purging, and encouraging excessive exercise (D) can lead to further health complications.
The client tells the nurse, 'My husband left to go bowling with his buddies, so I had to cut myself.' The nurse using the SET method of communication will use as the initial response:
- A. Tell me what made you think of that action.'
- B. It concerns me to hear that you took that action.'
- C. You should have called your psychiatrist.'
- D. What can I do to help you now that you're here?'
Correct Answer: B
Rationale: The correct answer is B: "It concerns me to hear that you took that action." The rationale for this is that this response demonstrates empathy and concern for the client's well-being, which is essential in building a therapeutic relationship. It acknowledges the client's statement without judgment and opens the door for further exploration of the client's feelings and reasoning behind the self-harm.
Choice A: "Tell me what made you think of that action" may come across as too direct and could be perceived as insensitive or confrontational, potentially shutting down communication.
Choice C: "You should have called your psychiatrist" is dismissive and fails to address the client's emotional needs or offer support.
Choice D: "What can I do to help you now that you're here?" is forward-thinking and assumes the client is seeking help, which may not be the case. It also does not directly address the concerning behavior of self-harm.
Which nursing strategy leads patients to respond more positivity to limit setting?
- A. Confront the patient with the inappropriateness of the behavior.
- B. Explore with the patient the underlying dynamics of the behavior.
- C. Reflect back to the patient an understanding of the patient's distress.
- D. State clear disapproval of the behavior, and support its consequences.
Correct Answer: C
Rationale: The correct answer is C because reflecting back to the patient an understanding of their distress shows empathy and validation, which can help build rapport and trust. By acknowledging the patient's feelings, it can help them feel heard and understood, leading to a more positive response to limit setting.
Choice A is incorrect because confrontation can lead to defensiveness and resistance. Choice B focuses on exploring underlying dynamics without addressing the immediate behavior. Choice D may come off as judgmental and punitive, potentially escalating the situation.
Joey is a 5-year-old who is causing his parents a lot of concern. His mother reports that he bounces off the walls all the time and cant focus on any one thing for very long. He is impulsive and has recently ran right out into the street in front of the familys home. His teacher has told his parents that he has done similar things at school. The nurse understands that:
- A. Joey shows all the signs of having ADHD and should probably be placed on Ritalin as soon as possible
- B. Joey is just an active, healthy child who needs to be disciplined more effectively
- C. Joey could be autistic, and additional testing will have to be done to confirm the diagnosis
- D. Joey shows signs of having ADHD, but is too young for that diagnosis to be made definitively now
Correct Answer: D
Rationale: Definitive diagnosis of ADHD should not be made before age 7 because developmentally the child has a shorter attention span.