Nokea
The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)
- A. Purchase a gun to use for protection.
- B. Keep quiet and calm.
- C. Take a self-defense course that retaliates against the abuser with injury.
- D. Have a bag ready that has extra clothes for self and children.
Correct Answer: C
Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.
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At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?
- A. 'Yes, I am the leader today. Would you like to be the leader tomorrow?'
- B. 'Yes, I will be leading this group. What would you like to accomplish during this time?'
- C. 'Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.'
- D. 'Yes, I am the leader. You seem angry about not being the leader yourself.'
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?
- A. Isolation.
- B. Stagnation.
- C. Despair.
- D. Role confusion.
Correct Answer: B
Rationale: The client is in Erikson's 'Generativity vs. Stagnation' stage (age 24 to 45). This stage involves maintaining intimate relationships and moving toward developing a family, which the client seems to be struggling with due to lack of visitors and family support. Choices (A), (C), and (D) are incorrect. Isolation typically occurs in young adulthood (age 18 to 25), Despair in maturity (age 45 to death), and Role confusion in adolescence (age 12 to 20). These stages reflect challenges individuals face if they do not successfully navigate their psychosocial developmental tasks.
A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?
- A. Reassure the client that no one will harm her while she is in the hospital.
- B. Ask the healthcare provider to give the client the medication.
- C. Explain the importance of taking the diabetic medication.
- D. Reassess the client's mental status for thought processes and content.
Correct Answer: D
Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?
- A. Acute confusion.
- B. Ineffective community coping.
- C. Disturbed sensory perception.
- D. Self-care deficit.
Correct Answer: A
Rationale: Acute confusion is the priority problem as it directly affects the client's ability to process information and make safe decisions. In this scenario, the client's disorientation, disorganization, and confusion indicate an immediate cognitive issue that requires attention to ensure her safety and stability. Choices B, C, and D are not the priority problems in this case. Ineffective community coping, disturbed sensory perception, and self-care deficit, while important, are secondary to the client's acute confusion, which poses an immediate risk to her well-being.
A female client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. What is the priority nursing intervention?
- A. Monitor the client's vital signs regularly.
- B. Encourage the client to participate in group therapy.
- C. Offer the client frequent, high-calorie snacks.
- D. Weigh the client daily at the same time.
Correct Answer: D
Rationale: The correct answer is to weigh the client daily at the same time. Daily weights are crucial in monitoring the client's nutritional status and guiding treatment for weight restoration in anorexia nervosa. Monitoring vital signs is important but weighing the client daily takes precedence in this situation. Encouraging group therapy and offering high-calorie snacks are important aspects of treatment but do not take priority over monitoring the client's weight.