Nokea
When a victim of sexual assault is discharged from the emergency department, the nurse should:
- A. Notify the patient's family of the event to ensure support for the patient.
- B. Offer to stay with the patient until stability is regained.
- C. Advise the patient to try not to think about the assault.
- D. Provide referral information verbally and in writing.
Correct Answer: D
Rationale: The correct answer is D because providing referral information verbally and in writing ensures that the victim has access to appropriate resources for follow-up care and support. This step is crucial in helping the victim navigate the emotional and physical aftermath of the assault.
A: Notifying the patient's family without the patient's consent could violate the patient's privacy and autonomy.
B: While offering to stay with the patient shows support, it may not always be feasible and may not address the victim's long-term needs.
C: Advising the patient to try not to think about the assault is dismissive of their trauma and does not provide constructive support.
You may also like to solve these questions
Which nursing progress note would most suggest that the treatment plan of a severely depressed and withdrawn patient has been effective?
- A. Slept 6 hours straight, sang with activity group, eager to see grandchild.
- B. Slept 8 hours, attended craft group, ate half of lunch, denies suicidal ideation.
- C. Slept 10 hours, personal hygiene adequate with assistance, lost one pound.
- D. Slept 7 hours on and off, reports "food has no taste", no self-harm noted.
Correct Answer: A
Rationale: The correct answer is A because it indicates positive changes in mood, engagement, and social interaction, which are key indicators of effective treatment for severe depression. Sleeping 6 hours straight shows improved sleep patterns, singing with the activity group reflects increased participation and enjoyment, and being eager to see the grandchild demonstrates a renewed sense of joy and connection.
Choice B is incorrect because although the patient denies suicidal ideation, the level of activity and engagement is not as high as in choice A. Choice C is incorrect as the focus is on physical aspects rather than emotional well-being and social interaction. Choice D is incorrect because the patient still shows signs of depression such as lack of appetite and loss of interest in activities.
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another client a 'jerk' without provocation. The nurse asks the client how he is feeling, and he responds, 'Everybody picks on me. They frobitz me.' The nurse would assess 'frobitz' as:
- A. Circumstantial speech
- B. Loose associations
- C. Evidence of delusional thinking
- D. A neologism
Correct Answer: D
Rationale: The correct answer is D: A neologism. A neologism is a newly created word or phrase that is unique to the individual and not understandable to others. In this scenario, the client's use of the word 'frobitz' is an example of a neologism. This demonstrates disorganized thinking and language typical of schizophrenia.
A: Circumstantial speech involves providing unnecessary details before reaching the main point, which is not evident in the client's response.
B: Loose associations involve a lack of logical connection between thoughts, which is not demonstrated by the client's use of 'frobitz.'
C: Delusional thinking involves fixed false beliefs, which are not explicitly present in the client's response.
In summary, the client's use of 'frobitz' indicates a neologism, reflecting disorganized thinking in schizophrenia, making it the correct assessment.
Which of the following are behaviours that may be associated with adolescent depression?
- A. School refusal
- B. Social withdrawal
- C. Reduced self-care
- D. Maladaptive coping behaviours
Correct Answer: A
Rationale: School refusal is a well-documented behavior associated with adolescent depression; the question implies a single correct answer, though B-D are also relevant.
Which nursing intervention has highest priority for a patient with bulimia nervosa?
- A. Assist the patient to identify triggers to binge eating.
- B. Provide remedial consequences for weight loss.
- C. Assess for signs of impulsive eating.
- D. Explore needs for health teaching.
Correct Answer: A
Rationale: The correct answer is A: Assist the patient to identify triggers to binge eating. The highest priority for a patient with bulimia nervosa is addressing the root cause of the behavior, which is often triggered by emotional or situational factors. By identifying triggers, the patient can learn to recognize and manage them effectively, ultimately reducing the frequency of binge eating episodes. This intervention focuses on addressing the underlying issue and promoting long-term recovery.
Summary:
B: Providing remedial consequences for weight loss is not the priority as the main concern is addressing the binge eating behavior.
C: Assessing for signs of impulsive eating is important, but identifying triggers takes precedence in addressing the behavior.
D: Exploring needs for health teaching may be relevant, but addressing triggers to binge eating is more immediate and crucial for managing bulimia nervosa.
To plan effective interventions, the nurse should understand that the underlying reason a patient with paranoid personality disorder is so critical of others probably lies in the patient's:
- A. need to control all aspects of the world around him.
- B. use of intellectualization to protect against anxiety.
- C. inflexible view of the environment and the people in it.
- D. projection of blame for his own shortcomings onto others.
Correct Answer: D
Rationale: The correct answer is D because paranoid personality disorder is characterized by distrust and suspicion of others, leading individuals to project their own negative traits onto others (projection). This defense mechanism helps them avoid accepting their own shortcomings. Option A is incorrect because the focus is on control, not blame. Option B is incorrect as intellectualization is a defense mechanism that involves avoiding emotions by focusing on rational aspects. Option C is incorrect as it refers to rigidity and not projection of blame. In summary, projection of blame onto others is the underlying reason for the critical behavior in paranoid personality disorder.