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The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. What components should the plan include? Select all that apply.
- A. A code word to signal children that it is time to leave.
- B. Phone numbers for the nearest shelter and crisis hotline.
- C. Telling the spouse that she has a plan and will leave.
- D. Collecting birth certificates and other essential documents.
Correct Answer: A
Rationale: The correct answer is A: A code word to signal children that it is time to leave. This is crucial for ensuring the safety of the victim and their children without alerting the abuser. Other choices like B, providing phone numbers for shelters, are important but may not always be feasible in an emergency. Choice C, informing the spouse about the plan, can escalate the situation. Choice D, collecting essential documents, is important but may not always be the immediate priority in a dangerous situation. Having a code word ensures a discreet and quick escape if needed.
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A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his specific delusion of food being poisoned. By allowing the client to select food from vending machines, he can choose items he believes are safe, which can help alleviate his paranoia and increase his trust in the care being provided. This approach promotes a therapeutic relationship and empowers the client in making choices about his care.
Explanation of why other choices are incorrect:
A: Explaining that others eat the food and are not harmed may not be effective as the client's delusion is strong, and rational arguments may not be helpful in this case.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's delusion about food being poisoned.
D: Not allowing the client to verbalize delusional thoughts can escalate the client's distress and hinder the therapeutic relationship. It is essential to acknowledge the client's experiences and work towards building trust and rapport
A person who was raped comes to the hospital for treatment. The person abruptly decides to decline treatment and leave the facility. Before this person leaves, the nurse should:
- A. Say, "You may not leave until you're given prophylactic treatment for sexually transmitted diseases."Â
- B. Provide written information about physical and emotional reactions the person may experience.
- C. Explain the need and importance of HIV and pregnancy tests.
- D. Give verbal information about legal resources.
Correct Answer: B
Rationale: The correct answer is B because providing written information about physical and emotional reactions respects the individual's autonomy and empowers them to make informed decisions. It also ensures they have resources to understand and cope with potential consequences. Choice A violates the individual's right to refuse treatment. Choice C focuses on specific tests without addressing the person's immediate concerns. Choice D, while important, is not as immediate or relevant as providing information on potential reactions.
Features of schizoid personality include.
- A. Hyper-vigilant ready for real or imagines threat
- B. Inability to respond to others, hyper-vigilant
- C. Social withdrawal, inability to respond to others
- D. Ready for real or imagined threat, social withdrawal
Correct Answer: C
Rationale: Schizoid personality disorder is characterized by social withdrawal and emotional detachment, with little interest in relationships.
Your pregnant patient has a history of major depression. Which of the following is she most likely to be at risk for?
- A. She is at risk for development of manic episodes.
- B. She is at risk for recurrence of depression after the birth of the baby.
- C. She is more likely to have an autistic child.
- D. She has no higher risk for emotional problems than other patients.
Correct Answer: B
Rationale: History of major depression (B) is the biggest risk factor for postpartum depression, increasing the likelihood of recurrence post-delivery.
A common form of mental disorder afflicting 10-20\% of the population is
- A. schizophrenia
- B. senile dementia
- C. depression
- D. delusional disorder
Correct Answer: C
Rationale: Depression affects 10-20\% of people at some point, making it far more common than schizophrenia or delusional disorders.