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Which of these assessment findings would indicate that a rape victim is exhibiting behavior typically seen in the acute stage of sexual assault?
- A. Patient is very demanding and controlling in manner when dealing with staff.
- B. Patient appears to be confused, restless, and fearful when left alone.
- C. Patient uses profanity to describe the events surrounding the attack.
- D. Patient experiences a panic attack on the anniversary of the attack.
Correct Answer: B
Rationale: The correct answer is B because exhibiting confusion, restlessness, and fear when left alone aligns with the acute stage of sexual assault trauma. During this stage, victims often experience shock, disbelief, and heightened anxiety. This behavior reflects immediate emotional distress and trauma response. Choice A indicates characteristics of control and demanding behavior, which are not typically seen in the acute stage. Choice C suggests using profanity, which may vary based on individual coping mechanisms. Choice D indicates a specific trigger response on the anniversary, suggesting a later stage of processing trauma, not the acute phase.
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What is the priority nursing intervention for a patient with bulimia nervosa who is engaging in purging behaviors?
- A. Monitor electrolyte levels and cardiac function.
- B. Encourage self-monitoring of food intake.
- C. Provide emotional support and promote body image acceptance.
- D. Focus on encouraging weight loss through diet control.
Correct Answer: A
Rationale: The correct answer is A. The priority nursing intervention for a patient with bulimia nervosa engaging in purging behaviors is to monitor electrolyte levels and cardiac function. This is crucial due to the potential electrolyte imbalances and cardiac complications resulting from purging behaviors. Monitoring these parameters helps prevent life-threatening conditions such as hypokalemia and arrhythmias.
Option B is incorrect as self-monitoring of food intake may not address the immediate health risks associated with purging behaviors. Option C is also incorrect as emotional support and body image acceptance are important but not the immediate priority in this case. Option D is incorrect as focusing on weight loss through diet control can exacerbate the patient's eating disorder behaviors and does not address the urgent medical concerns associated with purging.
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.
Confidentiality should be discussed with all adolescents and parents before the consult. Confidentiality may be breached in all situations below EXCEPT:
- A. Disclosure of sexual abuse
- B. Disclosure of drug abuse
- C. Disclosure of suicidality
- D. Disclosure of dropping grades
Correct Answer: D
Rationale: Confidentiality can be breached for safety concerns (abuse, drug use, suicidality), but dropping grades is not a direct threat to safety or health, so it does not warrant breaching confidentiality.
What is the primary source of mental stimulation in early childhood?
- A. Television
- B. Parental interaction
- C. Toys
- D. School lessons
Correct Answer: B
Rationale: Parental interaction (B) provides responsive, tailored stimulation critical for early mental development. TV (A) and toys (C) are less interactive, and school lessons (D) come later.
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.