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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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A person suffering from hypoactive sexual desire disorder has:
- A. Too little interest in sex
- B. Too much interest in sex
- C. An obsessive need to expose their genitals in public
- D. A desire to witness suffering in other people
Correct Answer: A
Rationale: Hypoactive sexual desire disorder is defined by a persistent lack of sexual interest or desire.
If a person suffering from schizophrenia has an identical twin, that twin
- A. will have a 46 percent chance of becoming schizophrenic
- B. will be no more likely than anyone else to become schizophrenic
- C. is almost sure to become schizophrenic
- D. is also likely to have more than one personality
Correct Answer: A
Rationale: Identical twins share genetics, giving a 46% concordance rate for schizophrenia, reflecting strong genetic influence.
A patient reports an intense, overwhelming fear of driving a car. The fear has disrupted all elements of the patient's life. The patient does not go to the grocery store unless driven by someone else, has relinquished their job, and has few social contacts. The patient's treatment plan includes:
- A. assertiveness training
- B. biofeedback
- C. stress management assistance
- D. systematic desensitization
Correct Answer: D
Rationale: Systematic desensitization gradually exposes the patient to driving-related stimuli, reducing phobia through controlled steps.
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.
What is the most effective strategy for preventing relapse in patients with anorexia nervosa?
- A. Providing a strict, rigid meal plan that the patient must follow.
- B. Offering frequent, supportive counseling to address underlying issues.
- C. Encouraging the patient to self-monitor their food intake only.
- D. Reassuring the patient that their weight will stabilize without further intervention.
Correct Answer: B
Rationale: The correct answer is B because offering frequent, supportive counseling to address underlying issues is the most effective strategy for preventing relapse in patients with anorexia nervosa. Counseling helps patients explore and work through the root causes of their disorder, such as body image issues, low self-esteem, or past trauma. It also provides ongoing support and guidance in developing healthy coping mechanisms and behaviors.
Choice A is incorrect because providing a strict, rigid meal plan can exacerbate feelings of control and restriction, which are common triggers for relapse in individuals with anorexia nervosa.
Choice C is incorrect as solely focusing on self-monitoring food intake may not address the psychological and emotional factors contributing to the disorder, which are crucial for long-term recovery.
Choice D is incorrect because reassuring the patient that their weight will stabilize without further intervention ignores the complexities of anorexia nervosa and does not address the underlying issues that need to be resolved for sustained recovery.