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Which of the following interventions should the nurse plan to use to reduce client focus on delusional thinking?
- A. Confronting the delusion
- B. Focusing on feelings suggested by the delusion
- C. Refuting the delusion with logic
- D. Exploring reasons the client has the delusion
Correct Answer: B
Rationale: The correct answer is B: Focusing on feelings suggested by the delusion. By addressing the underlying emotions associated with the delusion, the nurse can help the client process and cope with their feelings, ultimately reducing the intensity of the delusional thinking. Confronting the delusion (A) may lead to resistance and escalation. Refuting the delusion with logic (C) can be ineffective as it may reinforce the client's belief. Exploring reasons for the delusion (D) may not directly address the client's focus on delusional thinking.
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A woman has concerns about a man she recently began to date. She confides to her friend, a nurse in the clinic, that she recently discovered that he had been charged with domestic violence in a previous relationship. She asks if this means he will also hurt her and what signs would indicate that he is likely to be abusive. What should the nurse tell her friend?
- A. If he hasn't been abusive or controlling so far, chances are he won't be abusive later.
- B. Abuse occurs within dysfunctional relationships, so it may not occur in your situation.
- C. Danger signs include pathological jealousy and controlling the partner's activities.
- D. Because you are not masochistic or provocative, it is unlikely you will be abused.
Correct Answer: C
Rationale: The correct answer is C because it provides specific warning signs of potential abuse, such as pathological jealousy and controlling behavior. These behaviors are often early indicators of an abusive relationship. Option A is incorrect as past behavior can indicate future behavior. Option B is not correct as abuse can occur in any type of relationship. Option D is also incorrect as it implies that abuse is the fault of the victim, which is not true. It is important to educate the woman on recognizing red flags and seeking help if needed.
A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after experiencing an event in which self-esteem is challenged. The most recent episodes of violence were related to feeling 'upset' over a job loss. What type of therapy would provide the greatest help to the victim?
- A. Individual therapy
- B. Group therapy
- C. Couples therapy
- D. Family therapy
Correct Answer: A
Rationale: The correct answer is A: Individual therapy. In this scenario, individual therapy would be most beneficial because it allows the victim to focus on healing and developing coping strategies for dealing with the abuse and rebuilding self-esteem. Addressing the victim's psychological well-being and empowering them to recognize and address the abusive behavior is crucial. Group therapy (B) may not provide the necessary individualized support. Couples therapy (C) could potentially put the victim at further risk of harm. Family therapy (D) may not address the specific dynamics of the abusive relationship.
An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply.
- A. Body map.
- B. DNA swabs.
- C. Photographs.
- D. Pulse oximeter.
Correct Answer: A
Rationale: The correct answer is A: Body map. In cases of sexual assault, a body map is essential to document and track injuries and evidence. It helps in accurately recording the location and nature of injuries on the victim's body. DNA swabs and photographs are also important for collecting forensic evidence. DNA swabs can help in identifying the perpetrator, while photographs can visually document injuries and evidence. However, a pulse oximeter is not typically needed for collecting forensic evidence in cases of sexual assault. It is used to measure oxygen saturation in the blood and is not directly relevant to documenting forensic evidence in this context.
A patient tells a nurse, 'The others won't give me my pain meds early, but you are more understanding, you know what it's like to be in pain, and you don't want to see your patients suffer. Could you find a way to get me my pill now? I won't tell anyone.' Which response by the nurse would be most therapeutic?
- A. I'm not comfortable doing that,' then ignore subsequent requests for early meds.
- B. I'll have to check with your doctor about that; I will get back to you after I do.'
- C. It would be unsafe to give the medicine early; none of us will do that.'
- D. I understand that you have pain, but giving medicine too soon would not be safe.'
Correct Answer: D
Rationale: Step 1: Acknowledge the patient's pain and show understanding.
Step 2: Emphasize the importance of safety in medication administration.
Step 3: Set clear boundaries by explaining why giving medicine too soon is unsafe.
Step 4: Reiterate empathy for the patient's pain while prioritizing safety.
Summary: Answer D is correct as it acknowledges the patient's pain, emphasizes safety, sets clear boundaries, and maintains empathy. Other choices either ignore the patient's request, defer responsibility, or solely focus on safety without empathy.
A 79-year-old white male tells a nurse, 'I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.' The nurse should analyze this comment as:
- A. normal pessimism of the elderly
- B. evidence of risks for suicide
- C. a call for sympathy
- D. normal grieving
Correct Answer: B
Rationale: The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.