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The nursing diagnosis Rape-trauma syndrome is established for a rape victim in the emergency department. Select the most important outcome to achieve before discharging the patient!
- A. The patient will describe feelings of safety and relaxation.
- B. The memory of the rape will be less vivid and less frightening.
- C. Physical symptoms of pain and discomfort are no longer present.
- D. The patient will agree to keep a follow-up appointment with a rape victim advocate.
Correct Answer: D
Rationale: The correct answer is D. Establishing a follow-up appointment with a rape victim advocate is crucial for ongoing support and recovery. It ensures the patient has access to necessary resources and assistance in coping with the trauma. Choice A focuses on emotional well-being but doesn't address long-term support. Choice B addresses memory but doesn't ensure ongoing care. Choice C only addresses physical symptoms, neglecting the emotional and psychological impact of the trauma. Thus, choice D is the most important outcome to achieve before discharging the patient to promote comprehensive care and support.
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Treatment of communication disorders is normally the domain of speech therapists and related disciplines, and a range of successful treatment programmes and equipment are available for disabilities such as phonological disorder and stuttering (Saltuklaroglu & Kalinowski, 2005; Law, Garrett & Nye, 2004). For example, hand-held equipment can provide which of the following?
- A. Significant auditory feedback (SAF)
- B. Magnified auditory feedback (MAF)
- C. Altered auditory feedback (AAF)
- D. Actual auditory feedback (AAF)
Correct Answer: C
Rationale: Altered Auditory Feedback (AAF): A treatment for stuttering providing delayed auditory feedback or frequency changes to improve speech fluency.
A nurse has completed the assessment for a patient who 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; dissatisfied with eating pattern as evidenced by patient statement, 'I need to lose another 10 pounds to be at an ideal weight.' These assessment findings are most consistent with the medical diagnosis of:
- A. bulimia nervosa.
- B. anorexia nervosa.
- C. binge-eating disorder.
- D. disturbed body image.
Correct Answer: B
Rationale: The correct answer is B: Anorexia nervosa. The assessment findings align with the diagnostic criteria for anorexia nervosa, including significant weight loss, restrictive eating patterns, distorted body image, amenorrhea, and physical signs like poor skin turgor and lanugo. The patient's extreme weight loss, restrictive calorie intake, dissatisfaction with weight despite being underweight, and other physical and psychological symptoms are classic indicators of anorexia nervosa.
Incorrect Choices:
A: Bulimia nervosa involves binge eating followed by compensatory behaviors, which are not evident in this case.
C: Binge-eating disorder involves recurrent episodes of binge eating without compensatory behaviors, which are not present here.
D: Disturbed body image may be present in anorexia nervosa, but the key features of weight loss, restrictive eating, and amenorrhea are more indicative of anorexia nervosa.
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy."Â A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
- A. take the patient's vital signs.
- B. start intravenous fluids.
- C. administer a sedative.
- D. perform a mental status examination.
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
The nurse is explaining to the family of a patient diagnosed with schizophrenia that the disorder is considered to have neurobiological origins. When the patient's mother asks, 'What part of the brain is dysfunctional?' the nurse should reply, 'Research has implicated the:
- A. medulla and cortex.
- B. cerebellum and cerebrum.
- C. hypothalamus and medulla.
- D. prefrontal and limbic cortices.'
Correct Answer: D
Rationale: The correct answer is D: prefrontal and limbic cortices. The prefrontal cortex is involved in decision-making, planning, and social behavior, functions commonly impaired in schizophrenia. The limbic cortex regulates emotions and memory, areas affected in schizophrenia. Medulla (A, C) controls basic functions like breathing, not implicated in schizophrenia. Cerebellum (B) coordinates movement, unrelated to schizophrenia. Hypothalamus (C) regulates hormones, not directly linked to schizophrenia. In summary, D is correct as prefrontal and limbic cortices are key brain regions affected in schizophrenia, while the other choices are not directly involved in the disorder.
Which statements most clearly indicate the speaker views mental illness with stigma? Select one tha does not apply.
- A. We are all a little bit crazy.'
- B. If people with mental illness would go to church, their problems would be solved.'
- C. Many mental illnesses are genetically transmitted. Its no ones fault that the illness occurs.'
- D. People with mental illness are lazy. They get government disability checks instead of working.'
Correct Answer: C
Rationale: Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame.