Nokea
Which of the following individuals is at the highest risk of experiencing intimate partner violence?
- A. A 36-year-old woman who is recently divorced
- B. A 22-year-old man who is unemployed but living with friends
- C. A 20-year-old woman who grew up with a psychologically abusive father
- D. A 40-year-old man diagnosed with schizophrenia
Correct Answer: C
Rationale: Intimate partner violence is a serious issue encompassing physical, psychological, or sexual abuse within an intimate relationship. Individuals who have experienced psychological abuse in their upbringing are at a higher risk of becoming victims themselves due to the normalization of abusive behaviors. While factors such as age, mental health conditions, and social support can contribute to vulnerability, growing up in an abusive environment can significantly heighten the risk of intimate partner violence. The other options, such as recent divorce (A), unemployment (B), and schizophrenia diagnosis (D), do not directly correlate with the same level of increased risk associated with a history of psychological abuse.
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An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?
- A. "I know you are capable of giving yourself the insulin."
- B. "Giving yourself the injection seems to make you nervous."
- C. "When I watched you give yourself the injection, you did it correctly."
- D. "Tell me what you want me to do to help you give yourself the injection at home."
Correct Answer: C
Rationale: The most appropriate response by the nurse in this scenario is option C. By acknowledging and affirming the client's demonstrated ability to self-administer the injection correctly, the nurse is providing positive reinforcement. This positive reinforcement helps to build the client's confidence and encourages them to take total responsibility for their daily injections. Option A, while positive, does not specifically reinforce the client's behavior related to giving the injection. Option B focuses on the client's feelings of nervousness, which may not be helpful in promoting independence. Option D, by offering help without assessing the client's actual needs, reinforces dependence on the nurse rather than encouraging self-reliance.
A client is having difficulty applying for a job due to panic and anxiety. A nurse is helping by pretending to be the job supervisor while the client practices answering questions during an imaginary interview. This technique is an example of:
- A. Reinforcement
- B. Presenting reality
- C. Role playing
- D. Summarizing
Correct Answer: C
Rationale: Role-playing is the correct answer. It involves practicing appropriate behaviors during imaginary scenarios that simulate real-life situations. In this scenario, the nurse is helping the client prepare for a job interview by acting as the job supervisor. Role-playing allows the client to practice and develop strategies to cope with anxiety and panic during the actual interview. Reinforcement (Choice A) involves providing consequences to strengthen a behavior. Presenting reality (Choice B) involves helping the client differentiate between real and unreal experiences. Summarizing (Choice D) involves condensing information. In this context, role-playing is the most appropriate technique to address the client's anxiety and panic related to job interviews.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
- A. Review the chart for a signed consent for medication administration.
- B. Get the guardian's permission to give the medication.
- C. Do not give the medication and document the reason.
- D. Complete an incident report and notify the supervisor.
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take is not to administer the medication and document the reason. Since the adolescent client is a minor, parental or guardian consent is required for medical treatment, including medication administration. Option A, reviewing the chart for a signed consent for medication administration, is not the appropriate action in this situation as the focus is on parental consent for the client. Option B is incorrect because obtaining the health care provider's permission does not replace the need for parental consent for a minor. Option D, completing an incident report and notifying the supervisor, is unnecessary as there is no adverse event to report; the key concern is the lack of parental consent for medication administration.
To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?
- A. Instruct in the use of the incentive spirometer.
- B. Elevate the head of the bed during all meals.
- C. Use aseptic technique to change the dressing.
- D. Encourage frequent ambulation in the hallway.
Correct Answer: D
Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.
A client who just had a bilateral mastectomy is preparing to talk about body changes. Which of the following actions of the nurse is most appropriate during this discussion?
- A. Provide a room that offers minimal distractions
- B. Ask closed-ended questions to allow the client to think about her situation
- C. Write detailed notes during the conversation to track important information
- D. Ask personal questions about the client's background to determine how the procedure has affected her self-concept
Correct Answer: A
Rationale: When preparing to discuss sensitive topics such as body changes post-bilateral mastectomy, it is crucial to create a conducive environment. Providing a room with minimal distractions allows the client to feel comfortable, safe, and more likely to open up about personal feelings without interruptions. This setting fosters open communication between the nurse and client, facilitating a more empathetic and supportive interaction. Closed-ended questions (Choice B) may limit the client's ability to express emotions fully. Writing detailed notes (Choice C) during the conversation may distract the nurse from actively listening and being present for the client. Asking personal questions about the client's background (Choice D) may not be appropriate during such a vulnerable discussion and could potentially create discomfort for the client.