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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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Which of the following is a form of child abuse that is known to cause intellectual disability?
- A. Shaken baby syndrome
- B. Abused child syndrome
- C. Battered baby syndrome
- D. Damaged infant syndrome
Correct Answer: A
Rationale: Shaken Baby Syndrome: A form of child abuse causing intellectual disability through traumatic brain injury from violent shaking.
A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacantly. You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
- A. Pain, self-care deficits, situational low self-esteem
- B. Anxiety, self-care deficits, disturbed thought processes
- C. Impaired home maintenance, disturbed thought process, impaired verbal communication
- D. Disturbed body image, anxiety, pain
Correct Answer: C
Rationale: The correct answer is C: Impaired home maintenance, disturbed thought process, impaired verbal communication.
Rationale:
1. Impaired home maintenance: The client is unable to take care of herself and her living environment due to the need for assistance in shopping, meal preparation, and finances.
2. Disturbed thought process: The client's vacant stare and inability to learn new tasks suggest cognitive impairment or confusion.
3. Impaired verbal communication: The client's lack of verbal interaction and reliance on her sister for assessment data indicate difficulties in expressing herself.
Summary:
A: Pain, self-care deficits, situational low self-esteem - Pain is not mentioned in the scenario, and the client's issues go beyond self-care deficits and low self-esteem.
B: Anxiety, self-care deficits, disturbed thought processes - While anxiety and disturbed thought processes may be present, impaired home maintenance and impaired verbal communication are more appropriate diagnoses based on the scenario.
D: Disturbed body image, anxiety, pain - Disturbed
The nurse knows that stimulant medication for ADHD should be administered:
- A. At bedtime, to coincide with rising cortisol levels
- B. Only on school days to improve performance
- C. On an empty stomach
- D. With breakfast and lunch
Correct Answer: D
Rationale: Because these medications can contribute to insomnia, it is best to administer them earlier in the day with food. These are generally taken daily unless the doctor orders a drug holiday.
A child, age 9, is being evaluated in the Emergency Department at the hospital. Her mother reports that the child fell down the stairs in her home. Her mother is with her and describes her as a 'clumsy kid.' The nurse practitioner suspects child abuse. Which of these findings indicates that physical abuse may be a chronic problem for the child?
- A. Bloody nose and blackened eyes
- B. Unhealed fractures revealed on x-ray
- C. Clinging to her mother as she attempted to leave
- D. Struggling with the staff that attempts to obtain a blood specimen
Correct Answer: B
Rationale: The correct answer is B - Unhealed fractures revealed on x-ray. This finding indicates chronic physical abuse as unhealed fractures suggest repeated trauma over time. This is concerning because chronic abuse can lead to severe physical and emotional consequences for the child.
A: Bloody nose and blackened eyes may indicate acute physical abuse, but not necessarily chronic abuse.
C: Clinging to her mother as she attempted to leave is a behavior often seen in children who are anxious or scared in a medical setting, but it does not specifically indicate chronic physical abuse.
D: Struggling with the staff that attempts to obtain a blood specimen could be a response to fear or discomfort with medical procedures, which does not definitively point to chronic abuse.
A school-aged patient with attention-deficit hyperactivity disorder (ADHD) is displaying disruptive behaviors at home. The psychiatric-mental health nurse modifies the treatment plan for the social domain, by advising the patient's parents to:
- A. establish eye contact before giving directions
- B. initiate a point system, to reward the patient for appropriate behavior
- C. instruct the patient to work on one homework assignment at a time
- D. maintain a predictable environment in the home
Correct Answer: B
Rationale: A point system reinforces positive behavior, directly addressing social disruptiveness in ADHD.