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The nurse is planning care for a battered woman who has mentioned, 'Someday I'll have to leave him.' Which outcome should the nurse include in the plan of care for this client?
- A. Client will leave husband for a safe environment within 3 weeks
- B. Client will state that she feels more relaxed after consultation with nurse
- C. Client will state that she feels strong enough to return to the situation
- D. Client will verbalize awareness of the dangerousness of her situation
Correct Answer: D
Rationale: The correct answer is D: Client will verbalize awareness of the dangerousness of her situation. This outcome is crucial as it indicates the client's understanding of the risks involved in her current situation. By verbalizing awareness, the client is acknowledging the potential harm and taking a significant step towards recognizing the need for change. This outcome lays the foundation for further interventions and support.
Choice A is incorrect because setting a specific timeline for leaving may not be feasible or safe for the client. Choice B is incorrect as feeling relaxed does not necessarily address the underlying issue of abuse. Choice C is incorrect as feeling strong does not necessarily equate to recognizing the dangers of the situation. The focus should be on increasing awareness and empowering the client to make informed decisions.
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Which would be the best initial approach for a nurse to select when managing the care of an individual with two children who works full-time and has been abused by a partner?
- A. Teach the individual how to avoid provoking the abuser.
- B. Assist the individual in filing a police report describing the abuse.
- C. Help the individual to identify needs in order to best obtain support.
- D. Facilitate the individual's move into a safe house located near the current workplace.
Correct Answer: C
Rationale: The correct answer is C: Help the individual to identify needs in order to best obtain support. This is the best initial approach because it focuses on understanding the individual's specific needs and circumstances before taking any further action. By identifying needs, the nurse can create a tailored plan to provide appropriate support and resources.
Option A is incorrect because teaching the individual to avoid provoking the abuser places the responsibility on the victim rather than addressing the root cause of the abuse. Option B, filing a police report, may not be the best initial step as it may not take into consideration the individual's safety concerns or emotional well-being. Option D, moving the individual to a safe house, may not be feasible or desired by the individual without first understanding their needs and preferences.
A drug causes muscarinic receptor blockade. The nurse will assess the patient for
- A. Dry mouth.
- B. Gynecomastia.
- C. Pseudoparkinsonism.
- D. Orthostatic hypotension.
Correct Answer: A
Rationale: The correct answer is A: Dry mouth. Muscarinic receptor blockade inhibits the action of acetylcholine, leading to decreased salivary gland secretion and causing dry mouth. Gynecomastia (B) is associated with antiandrogen medications. Pseudoparkinsonism (C) is a side effect of antipsychotic medications that block dopamine receptors. Orthostatic hypotension (D) is a side effect of alpha-1 adrenergic receptor blockade.
The nurse has recently set limits for a patient with borderline personality disorder. The patient tells the nurse, 'You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're hateful.' Which phenomenon is represented by this response?
- A. Splitting
- B. Denial
- C. Reaction formation
- D. Projection
Correct Answer: A
Rationale: The correct answer is A: Splitting. Splitting is a defense mechanism commonly seen in individuals with borderline personality disorder where they perceive others as either all good or all bad. In this scenario, the patient's sudden shift from viewing the nurse as wonderful to hateful demonstrates splitting. The patient is unable to integrate both positive and negative aspects of the nurse's behavior, leading to extreme and polarized perceptions.
Choice B: Denial involves refusing to accept reality to protect oneself from uncomfortable truths, which is not demonstrated in this response.
Choice C: Reaction formation is a defense mechanism where an individual behaves in a way that is opposite to their true feelings, which is not evident in the patient's response.
Choice D: Projection involves attributing one's own unacceptable thoughts or feelings onto someone else, which is not the case in this scenario.
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse assesses the client's stage of Alzheimer's disease as stage:
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B (stage 2) because the client is exhibiting symptoms of moderate Alzheimer's disease, such as paranoia and delusions. In stage 2, cognitive decline becomes more noticeable, leading to memory loss, confusion, and behavioral changes. The client's accusations and false beliefs indicate a decline in reality orientation, which is characteristic of stage 2. Choices A, C, and D are incorrect because stage 1 is characterized by mild cognitive decline, stage 3 by severe cognitive decline, and stage 4 by very severe cognitive decline.
A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest?
- A. Determine the nature and extent of the coach's sexual disorder.
- B. Assess the coach's potential for suicide or other self-harm.
- C. Assess the coach's self-perception of problem and needs.
- D. Determine whether other children were harmed.
Correct Answer: B
Rationale: The correct answer is B: Assess the coach's potential for suicide or other self-harm. This is the priority nursing action because the coach may be experiencing intense emotional distress and may be at risk for harming themselves. By assessing for suicidal ideation or self-harm, the nurse can ensure the coach's safety and provide appropriate interventions if needed.
Choice A is incorrect because determining the nature and extent of the coach's sexual disorder is not the priority at this moment. Choice C is also incorrect as assessing the coach's self-perception of the problem and needs can be addressed after ensuring their immediate safety. Choice D is incorrect as determining whether other children were harmed is important but not the priority immediately following the coach's arrest.