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Which would be the best initial approach for a nurse to select when managing the care of an individual with two children who works full-time and has been abused by a partner?
- A. Teach the individual how to avoid provoking the abuser.
- B. Assist the individual in filing a police report describing the abuse.
- C. Help the individual to identify needs in order to best obtain support.
- D. Facilitate the individual's move into a safe house located near the current workplace.
Correct Answer: C
Rationale: The correct answer is C: Help the individual to identify needs in order to best obtain support. This is the best initial approach because it focuses on understanding the individual's specific needs and circumstances before taking any further action. By identifying needs, the nurse can create a tailored plan to provide appropriate support and resources.
Option A is incorrect because teaching the individual to avoid provoking the abuser places the responsibility on the victim rather than addressing the root cause of the abuse. Option B, filing a police report, may not be the best initial step as it may not take into consideration the individual's safety concerns or emotional well-being. Option D, moving the individual to a safe house, may not be feasible or desired by the individual without first understanding their needs and preferences.
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A patient asks, 'What advantage does a durable power of attorney for health care have over a living will?' The nurse should reply, 'A durable power of attorney for health care:
- A. gives your agent authority to make decisions during any illness if you are incapacitated
- B. can be given only to a relative, usually the next of kin, who has your best interests at heart
- C. can be used only if you have a terminal illness and become incapacitated
- D. cannot be implemented until 30 days after the documents are signed
Correct Answer: A
Rationale: A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individuals agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individuals behalf.
A community health nurse is working with a family in which an elderly woman was neglected by her son and his wife. The elderly woman insists on remaining with the young couple despite the threat of future neglect. Which intervention should be given highest priority?
- A. Identify community resources to decrease the caregivers' stress.
- B. Establish family obligations, client rights, and consequences of abuse and monitor.
- C. Educate the caregivers on the aging process and how to cope with it.
- D. Provide stress management techniques for the caregivers.
Correct Answer: B
Rationale: The correct answer is B because establishing family obligations, client rights, and consequences of abuse is crucial in protecting the elderly woman from neglect. By setting clear boundaries and educating the family on their responsibilities and the consequences of neglect, the nurse can help ensure the woman's safety. This intervention addresses the root cause of the issue and empowers the family to understand and fulfill their duties.
Choice A is incorrect as solely focusing on decreasing caregivers' stress may not address the underlying neglect. Choice C is incorrect as educating caregivers on the aging process does not directly address the neglect issue. Choice D is incorrect as providing stress management techniques does not address the root cause of neglect or establish accountability within the family.
A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
- A. Disturbed thought processes and Risk for other-directed violence
- B. Spiritual distress and Social isolation
- C. Risk for loneliness and Knowledge deficit
- D. Disturbed personal identity and Nonadherence
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence.
1. Disturbed thought processes: The patient's delusion of being plotted against by the physicians indicates impaired thought processes typical of paranoid schizophrenia.
2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violent acts towards others due to his paranoid beliefs.
Summary of why other choices are incorrect:
B: Spiritual distress and Social isolation are not primary concerns given the patient's acute symptoms of paranoia and risk for violence.
C: Risk for loneliness and Knowledge deficit are not crucial at this point as the patient's primary issues are related to paranoia and violence.
D: Disturbed personal identity and Nonadherence are not relevant to the immediate safety and mental health concerns presented by the patient.
The nurse is planning care for a battered woman who has mentioned, 'Someday I'll have to leave him.' Which outcome should the nurse include in the plan of care for this client?
- A. Client will leave husband for a safe environment within 3 weeks
- B. Client will state that she feels more relaxed after consultation with nurse
- C. Client will state that she feels strong enough to return to the situation
- D. Client will verbalize awareness of the dangerousness of her situation
Correct Answer: D
Rationale: The correct answer is D: Client will verbalize awareness of the dangerousness of her situation. This outcome is crucial as it indicates the client's understanding of the risks involved in her current situation. By verbalizing awareness, the client is acknowledging the potential harm and taking a significant step towards recognizing the need for change. This outcome lays the foundation for further interventions and support.
Choice A is incorrect because setting a specific timeline for leaving may not be feasible or safe for the client. Choice B is incorrect as feeling relaxed does not necessarily address the underlying issue of abuse. Choice C is incorrect as feeling strong does not necessarily equate to recognizing the dangers of the situation. The focus should be on increasing awareness and empowering the client to make informed decisions.
After taking an antidepressant for about a week, a patient reports constipation and blurred vision, with no improvement in mood. The psychiatric-mental health nurse informs the patient,:
- A. It takes approximately two to four weeks for depression to lessen, and side effects usually diminish over time'
- B. Stop the medication immediately and contact your primary care physician'
- C. You should contact your doctor. The doctor may need to change your medication'
- D. You should schedule an appointment with your ophthalmologist'
Correct Answer: A
Rationale: Antidepressants require 2-4 weeks for therapeutic effect, and early side effects often subside, making this the most reassuring response.