Nokea
The nurse who sees a number of battered women each year decides to put together a set of guidelines for nurses. An appropriate guideline to include, with the victims' informed consent, would be to:
- A. Take at least two photographs of each trauma area
- B. Assess for sexually transmitted disease
- C. Follow rape protocol even when rape is not suspected
- D. Make protective services aware of the abuse
Correct Answer: A
Rationale: The correct answer is A because taking photographs of trauma areas can provide crucial evidence for legal and medical purposes. It can help document the extent of injuries and aid in the prosecution of the abuser. This step is essential in ensuring proper documentation and care for the victims.
Option B is incorrect because assessing for sexually transmitted diseases may not be the immediate priority in cases of domestic violence. Option C is incorrect as following rape protocol when rape is not suspected may not be necessary and could potentially retraumatize the victim. Option D is incorrect because making protective services aware of the abuse should only be done with the victim's consent to ensure their safety and autonomy.
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An Arab student new to an elementary school reports, 'I just don't want to go to gym class.' Which factor would be of primary concern for a school nurse?
- A. The student's family's cultural beliefs regarding females interacting with males in public
- B. Complaints from others of 'bullying' that occurs in gym class
- C. The student's problems adjusting to the new school environment
- D. A teacher's concern that the gym class is overcrowded
Correct Answer: B
Rationale: The correct answer is B because the primary concern for the school nurse would be addressing any potential bullying the Arab student is experiencing in gym class. This is important for the student's well-being and mental health. Choice A is not the primary concern as it does not directly address the student's reluctance to attend gym class. Choice C focuses on general adjustment issues, while choice D pertains to a logistical issue rather than the student's emotional or social well-being. Addressing bullying is crucial to creating a safe and inclusive environment for the student.
A patient with schizophrenia has been stabilized in the Crisis Center and is about to be discharged. He will be living with his family, but the family knows nothing about the patient's illness, its treatment, or the role they can play in his recovery. Which activity would be most beneficial for the family to attend?
- A. Psychoanalytic group
- B. Psychoeducational group
- C. Individual counseling
- D. Family therapy
Correct Answer: B
Rationale: The correct answer is B: Psychoeducational group. This option is most beneficial as it provides education and information to the family about the patient's illness, treatment options, and ways they can support his recovery. It helps them understand the challenges the patient faces and equips them with practical strategies to assist in his recovery process.
A: Psychoanalytic group focuses on exploring unconscious patterns of behavior and may not provide the necessary education and tools for the family to support the patient effectively.
C: Individual counseling is focused on the patient and may not involve the family members in understanding the illness and their role in the patient's recovery.
D: Family therapy involves the whole family in therapy sessions, but may not specifically focus on educating them about schizophrenia and its treatment, which is crucial for their support.
A victim of rape says, "My family is not very supportive."Â Which belief contributes to a negative family response?
- A. No one asks to be raped.
- B. Rape is an act of aggression.
- C. Rape should not be discussed.
- D. Anyone is a potential rape victim.
Correct Answer: C
Rationale: The correct answer is C: Rape should not be discussed. This belief contributes to a negative family response because it promotes silence and stigma around the topic of rape, leading to lack of support and understanding for the victim. By not discussing rape, the victim may feel isolated, ashamed, and unable to seek help or share their experience. Choices A and B are incorrect as they acknowledge the victim's innocence and the violent nature of rape. Choice D is incorrect as it recognizes the reality that anyone can be a victim, but it does not directly address the issue of discussing rape within the family.
A patient has a maladaptive response to eating regulation. Findings include the following: height, 5 feet 3 inches; current weight, 80 pounds with weight loss of 30% of body weight over the past 3 months; T, 96.6m F; BP, 68/40; P, 40; R, 20; poor skin turgor; lanugo; amenorrhea of 6 months' duration; admits to restricting intake to 350 calories daily; is a vegetarian; dissatisfied with eating pattern as evidenced by patient statement, 'I need to lose another 10 pounds to be at ideal weight'; diagnostic testing reveals serum potassium of 2.9 mEq/L and urine specific gravity of 1.028. Which of the following would be the highest priority nursing diagnosis for this patient?
- A. Imbalanced nutrition, less than body requirements.
- B. Disturbed body image.
- C. Deficient fluid volume.
- D. Powerlessness.
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume. The patient is displaying signs of severe malnutrition and dehydration, as evidenced by significant weight loss, low blood pressure, low heart rate, and poor skin turgor. The low serum potassium and high urine specific gravity indicate dehydration. Addressing fluid volume deficiency is the top priority to stabilize the patient's condition and prevent further complications like electrolyte imbalances and organ damage. Choices A and B are important but secondary to addressing the immediate threat of dehydration. Choice D is not the priority as the patient's primary concern is physiological rather than psychological.
Confidentiality should be discussed with all adolescents and parents before the consult. Confidentiality may be breached in all situations below EXCEPT:
- A. Disclosure of sexual abuse
- B. Disclosure of drug abuse
- C. Disclosure of suicidality
- D. Disclosure of dropping grades
Correct Answer: D
Rationale: Confidentiality can be breached for safety concerns (abuse, drug use, suicidality), but dropping grades is not a direct threat to safety or health, so it does not warrant breaching confidentiality.