Nokea
The nurse is assessing an elder who the nurse suspects is being physically abused. The most important question for nurse to ask is:
- A. How much money do you keep around the house?
- B. Who provides your physical care?
- C. How close does your nearest relative live?
- D. What form of transportation do you use?
Correct Answer: B
Rationale: The most common abuser is a caregiver living with the client. Research reveals that the spouse is currently the most common abuser, followed by an adult child.
You may also like to solve these questions
A woman asks, 'How much alcohol can I safely drink while pregnant?' The nurse's best response is:
- A. The amount of alcohol that is safe during pregnancy is unknown.'
- B. Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.'
- C. Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.'
- D. You can have a drink to help you relax and get to sleep at night.'
Correct Answer: A
Rationale: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.
A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
- A. General anxiety disorder
- B. Schizophrenia
- C. Post-traumatic stress disorder
- D. Bipolar disorder
Correct Answer: C
Rationale: Childhood sexual abuse is strongly associated with post-traumatic stress disorder (PTSD), characterized by nightmares, insomnia, and concentration difficulties.
A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
- A. Male victims of sexual abuse seldom have long-term psychological problems.
- B. Survivors of male sexual abuse might become confused about their sexual identity.
- C. Unless treated, all male sex abuse survivors grow up to abuse other children.
- D. All children who have been sexually abused have the same needs, regardless of gender.
Correct Answer: B
Rationale: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts.
Appropriate nursing strategies to assist a client in maintaining a sense of self include:
- A. using the client's first name when addressing the client
- B. treating the client with dignity
- C. explaining procedures only if the client is attentive
- D. discouraging the use of personal items
Correct Answer: B
Rationale: Treating the client with dignity respects their individuality and fosters a sense of self, unlike the other options, which may undermine autonomy or engagement.
A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about?
- A. The patient reports, 'I didn't keep my extremity elevated like the doctor asked me to.'
- B. The patient reports, 'I have been having pain in my left calf.'
- C. The patient reports, 'My left leg has really been itching.'
- D. The patient reports, 'The arthritis in my wrists is flaring up, when I put weight on my crutches.'
Correct Answer: B
Rationale: Pain may be indicating neurovascular complication.