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You are caring for a client who has been assessed as having a past history of violent and dangerous behaviors towards others. You, as the nurse, are concerned about this client's past history and the dangers that may adversely affect others including staff, visitors and other clients on the unit. What is the first thing that you should do to prevent violence towards others?
- A. Restrain the client
- B. Place the client in seclusion
- C. Get an order for a sedating medication
- D. Establish trust with the client.
Correct Answer: D
Rationale: Establishing trust (D) is the first step to de-escalate potential violence.
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A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient?
- A. Pain related to immobility
- B. Ineffective Individual Coping due to terminal stage of HIV
- C. Risk for Injury due to impaired mobility, weakness, and weight loss
- D. Risk for Infection due to weak immune system and parenteral therapy
Correct Answer: D
Rationale: The correct answer is D: Risk for Infection due to weak immune system and parenteral therapy. This is the priority nursing diagnosis because a patient with AIDS-related wasting syndrome is at high risk for infections due to their weak immune system and parenteral therapy, which can introduce pathogens into the body. Addressing the risk for infection is crucial in preventing further complications and promoting the patient's overall well-being.
Choice A (Pain related to immobility) is not the priority as the patient's immobility is not the immediate concern compared to the risk of infection.
Choice B (Ineffective Individual Coping due to terminal stage of HIV) may be a valid concern, but ensuring the patient's physical health and preventing infections take precedence.
Choice C (Risk for Injury due to impaired mobility, weakness, and weight loss) is important but does not address the immediate threat of infection that the patient faces.
Describe three of the seven SFT interventions.
- A. Joining, boundary-making, unbalancing
- B. Lecturing, punishing, isolating
- C. Analyzing dreams, free association, transference
- D. Mediation, arbitration, negotiation
Correct Answer: A
Rationale: Joining builds rapport, boundary-making clarifies roles, unbalancing shifts power dynamics in SFT.
The psychosexual stage associated with autonomy is
- A. Oral
- B. Anal
- C. Phallic
- D. Genital
Correct Answer: B
Rationale: The anal stage (1-3 years) fosters autonomy through control mastery (Freud).
The control group and the experimental group in an experiment are treated exactly the same except for the:
- A. Dependent variable
- B. Independent variable
- C. Extraneous variables
- D. Replication variables
Correct Answer: B
Rationale: The independent variable is the only difference between control and experimental groups.
Which client has met the criteria for psychiatric homebound care?
- A. A 67-year-old retired teacher who has been depressed since the death of his longtime partner
- B. A 21-year-old diagnosed with paranoid schizophrenia who has delusions that the world is about to end
- C. A 45-year-old who, for the last 5 years, has experienced severe panic attacks whenever she attempts to leave her home
- D. A 16-year-old who has demonstrated obsessive-compulsive behaviors involving cleaning rituals since she was 10 years old
Correct Answer: C
Rationale: The correct answer is C because the client meets the criteria for psychiatric homebound care by experiencing severe panic attacks when trying to leave the home. This indicates significant impairment in functioning outside the home.
Explanation:
1. Criterion met: The client's severe panic attacks prevent her from leaving the home, indicating a need for care within the home environment.
2. Impairment in functioning: The client's panic attacks significantly impact her ability to engage in daily activities outside the home.
3. Duration of symptoms: The client has experienced these severe panic attacks for the last 5 years, indicating a chronic and persistent condition.
Summary of other choices:
A: Depression alone does not necessarily warrant psychiatric homebound care.
B: Delusions related to paranoid schizophrenia do not inherently restrict the client to homebound care.
D: Obsessive-compulsive behaviors, while impactful, do not specifically require homebound care unless they severely impair functioning outside the home.