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Which nurse would qualify as a fact witness in a case dealing with a physically abused young child?
- A. A psychiatric nurse
- B. A sexual assault nurse examiner nurse
- C. An emergency room nurse
- D. A pediatric intensive care unit nurse
Correct Answer: C
Rationale: The correct answer is C, an emergency room nurse. In cases of physical abuse, an emergency room nurse who directly treated the child and observed the injuries qualifies as a fact witness. They can provide firsthand accounts of the child's condition and the circumstances surrounding the incident. A psychiatric nurse (A) may not have direct knowledge of the physical abuse, focusing on mental health aspects. A sexual assault nurse examiner (B) specializes in sexual assault cases, not physical abuse. A pediatric intensive care unit nurse (D) may have limited interaction with the child and lack direct knowledge of the abuse.
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A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?
- A. Defensive coping
- B. Decisional conflict
- C. Risk for other-directed violence
- D. Impaired verbal communication
Correct Answer: D
Rationale: The correct answer is D: Impaired verbal communication. The patient's inability to speak, make eye contact, and focus on the speaker indicates a communication issue. Impaired verbal communication relates to difficulty expressing thoughts, feelings, or needs. The patient's behavior aligns with this diagnosis as they are mute, inattentive, and not making eye contact. Defensive coping (A) involves protecting oneself from emotional pain. Decisional conflict (B) pertains to uncertainty about choices. Risk for other-directed violence (C) involves potential harm to others, which is not evident in the scenario. Thus, D is the most appropriate nursing diagnosis.
The nurse has instructed a client with panic disorder about how to use the technique of positive self-talk. The nurse determines that the client has understood the instructions when the client verbalizes which statement to use during an impending panic attack?
- A. I am feeling very nervous right now.
- B. I can handle this anxiety; it will be over shortly.
- C. I am taking medication to eliminate these symptoms.
- D. Relax your muscles, relax your muscles.
Correct Answer: B
Rationale: The correct answer is B: "I can handle this anxiety; it will be over shortly." This statement reflects positive self-talk by acknowledging the anxiety but also affirming the client's ability to cope and that the situation is temporary. This empowers the client to manage the panic attack effectively.
Incorrect Choices:
A: "I am feeling very nervous right now." This choice focuses only on acknowledging the feeling without providing a positive coping strategy.
C: "I am taking medication to eliminate these symptoms." This choice relies solely on medication and does not address the client's ability to cope with the panic attack.
D: "Relax your muscles, relax your muscles." This choice provides a relaxation technique but lacks the empowering and affirming aspect of positive self-talk.
While leading a group, a nurse leader says to a patient, 'This is the fourth time that you've changed the subject when we have talked about child abuse. Is something going on?' The nurse is using which technique?
- A. Support
- B. Confrontation
- C. Summarizing
- D. Clarification
Correct Answer: B
Rationale: The correct answer is B: Confrontation. In this scenario, the nurse leader directly addresses the patient's behavior of changing the subject, which is a key aspect of confrontation technique. Confrontation is used to address discrepancies or inconsistencies in a nonjudgmental manner to promote self-awareness and insight. This technique encourages the patient to explore their thoughts and behaviors.
Incorrect Choices:
A: Support - Support involves providing empathy, understanding, and validation to the patient. The nurse in the scenario is not offering support, but rather challenging the patient's behavior.
C: Summarizing - Summarizing involves restating key points to ensure understanding and facilitate communication. The nurse's statement does not summarize but rather confronts the patient's behavior.
D: Clarification - Clarification is used to ensure mutual understanding by seeking clarification on unclear statements. The nurse's statement is not seeking clarification but rather addressing a specific behavior pattern.
The nurse is caring for an elderly client who has been taking an antipsychotic medication for 1 week. The nurse notifies the physician when he observes that the client has muscle rigidity that resembles Parkinson's disease. Which agent would the nurse expect the physician to prescribe?
- A. Anticholinergic
- B. Anxiolytic
- C. Benzodiazepine
- D. Beta-blocker
Correct Answer: A
Rationale: The correct answer is A: Anticholinergic. Antipsychotic medications can cause extrapyramidal symptoms like muscle rigidity resembling Parkinson's disease. Anticholinergics are used to manage these symptoms by blocking the effects of acetylcholine, which helps alleviate muscle rigidity. Anxiolytics (B), benzodiazepines (C), and beta-blockers (D) are not typically used to treat extrapyramidal symptoms associated with antipsychotic medications. Anxiolytics are for anxiety, benzodiazepines are for sedation or anxiety, and beta-blockers are for conditions like hypertension or heart-related issues.
A psychiatric-mental health nurse is working with a patient who is being treated for depression. Which patient statement would indicate that her spirituality is intact?
- A. My church friends came to visit me this past Sunday afternoon.'
- B. Nothing will ever be the same again; my life is not worth living.'
- C. I know I am as well off as I can be under the circumstances.'
- D. I know God must be punishing me for all my sins.'
Correct Answer: C
Rationale: The correct answer is C because the patient's statement reflects a sense of acceptance and inner peace despite challenging circumstances, indicating a belief in a higher power or spirituality. This indicates that her spirituality is intact.
Choice A implies social support but does not necessarily indicate spirituality. Choice B expresses hopelessness and suicidal ideation, which are not indicative of intact spirituality. Choice D reflects feelings of guilt and punishment, which do not align with a sense of spiritual well-being.