Nokea
Which reason(s) should the nurse expect a female client to use when she is having difficulty leaving a relationship where she is a victim of intimate partner violence? Select all that apply.
- A. Shame and guilt
- B. Children
- C. Religious beliefs about marriage
- D. The perpetrator will not change
- E. Financial dependency
Correct Answer: A,B,C,E
Rationale: A: Shame and guilt can prevent leaving due to fear of judgment. B: Children influence staying for their well-being or custody concerns. C: Religious beliefs about marriage may emphasize staying. E: Financial dependency is a common barrier. D: Belief the perpetrator won't change is not a reason to stay but rather a reason to leave.
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A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?
- A. Current vital signs
- B. White blood cell count
- C. 24-hour urinary output
- D. Blood sugar level
Correct Answer: A
Rationale: Current vital signs are critical for assessing NMS, a life-threatening side effect of haloperidol, indicated by fever, unstable blood pressure, and tachycardia. White blood cell count, urinary output, and blood sugar are less specific to NMS.
A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?
- A. Determine the type and size of the locks
- B. Plan a list of activities to be carried out daily
- C. Discuss checking the time frequently
- D. Ask the client why the locks are checked so frequently
Correct Answer: B
Rationale: Planning a list of daily activities helps establish a structured routine, reducing time spent on compulsive checking and promoting effective functioning. Determining lock types is irrelevant. Discussing time-checking does not address lock-checking. Asking 'why' may increase frustration, as compulsive behaviors are anxiety-driven.
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed
- B. Relax and reduce the amount of effort to solve the problem
- C. Shift attention from self to the needs and requests of others
- D. Focus on small achievable tasks, not taxing problems
Correct Answer: D
Rationale: Focusing on small achievable tasks promotes a sense of accomplishment, counteracting helplessness and supporting behavioral activation for depression. Ventilating emotions may not address avoidance. Reducing effort may worsen helplessness. Shifting attention to others does not directly address depressive symptoms.