Combo with "Ch 29 Sexual Assault" and 1 other

A nursing instructor is presenting statistics regarding suicide. Which student statement indicates that learning has occurred?

"Almost 95% of all individuals who commit or attempt suicide have a diagnosed mental disorder."

A nursing instructor is teaching about the cause of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders

"Evidence continues to support multiple causations related to an individual's susceptibility to mood symptoms.

You are assessing Lindy, a 25 year old woman who came to the emergency department with a broken arm. She states she slipped on the ice on the steps outside her home. She has numerous other bruises in different stages of healing. Her boyfriend, with whom she lives, accompanied her to the emergency department and aggressively responds to questions posed to the patient, while the patient remains silent. What is your best response to the boyfriend?

"I now need to examine Lindy in private. Please wait outside the room. I will come get you when we are finished."

A client diagnosed with major depressive disorder has an outcome that states, "The client will verbalize a measure of hope about future by day 3." Which client statement indicates this outcome was successful?

"I think I am going to talk to my boss about conflicts at work."

You are working at a telephone hotline center when Abby, a rape victim, calls. Abby states she is afraid to go to the hospital. What is your best response?

"I'm here to listen, and we can talk about your feelings."

A nurse is educating a patient about the causes of depression. Which statement lets the nurse know the patient understands the neurobiological theory of depression?

"If I take these medications as prescribed, I should start to think clearly and feel energized"

A client experiencing mania states, "Everything I do is great." Using a cognitive approach, which nursing response would be most appropriate

"Is there a time in your life when things didn't go as planned?"

Jamie, age 24, had been diagnosed with a dissociative disorder following a traumatic event. Jamie's mother asks you, "Does this mean my daughter is crazy now?" Your best response would be:

"Jamie is dealing with the anxiety associated with the trauma by separating herself from it. With treatment she can get back to her previous level of functioning."

A nursing student is studying major depressive disorder. Which student statement indicates that learning has occurred?

"Major depression is a leading cause of disability in the United States."

A female patient tells the nurse that she would like to begin taking St. John's wort for depression. What teaching should the nurse provide?

"St. John's wort has generally been shown to be effective in treating depression"

A nursing instructor is teaching about the psychosocial theory related to the development of bipolar disorder. Which student statement would indicate that learning has occurred?

"The etiology of bipolar disorder is unclear, but it is possible that biological and psy- chosocial factors are influential."

You are working in the emergency department caring for 21 year old Larissa, who has just been raped. Which is your INITIAL nursing response?

"You are safe here"

A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms?

(Risperdal) and (Lamictal).

Which of the following medications may be administered before electroconvulsive therapy? Select all that apply.

(Robinul). (Pentothal). (Anectine).

A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect that the client's lithium serum level would be which of the following?

2.6 mEq/L.

Which client is at highest risk for the diagnosis of major depressive disorders?

24 year old woman

Major depressive disorder would be most difficult to detect in which of the following clients?

A 13 year old boy.

1. A nurse is discussing silent rape reaction with a newly licensed nurse. Which of the following should the nurse identify as a characteristic of this type of reaction? (Select all that apply.) A. Sudden development of phobias B. Development of substance use disorder C. Increased level of anxiety during interview D. Reactivation of a prior physical disorder E. Unwillingness to discuss the sexual assault

A C E

Which is the key to understanding if a child or adolescent is experiencing an underlying depressive disorder?

A change in behavior over a 2 week period

A nurse is planning to teach about appropriate coping skills. The nurse would expect which client to be at the highest level of readiness to participate in this instruction?

A client admitted 6 days ago for suicidal ideations following a depressive episode.

What statement describes a major difference between a client dignosed with major depressive disorder and a client diagnosed with dysthymic disorder

A client diagnosed with dysthymic disorder has symptoms for at least 2 years

A nurse on an in-patient psychiatric unit receives report at 1500 hours. Which client would need to be assessed first?

A client pacing the hall and experiencing irritability and flight of ideas.

Which client would the charge nurse assign to an agency nurse working on the inpatient psychiatric unit for the first time?

A client rating mood as 3/10 and attending but not participating in group therapy.

A nurse is caring for an adult client who is the victim of intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A.Advise the client about the location of women's shelters. B.Encourage the client to participate in a support group for victims of abuse. C.Implement case management to coordinate community and social services. D.Educate the client about the use of stress management techniques.

A.CORRECT: The client's safety is the highest priority. Therefore, the development of a safety plan that includes the identification of safe places to live is the priority nursing action. B.INCORRECT: It is appropriate to encourage participation in a support group. However, this does not address the greatest risk to the client and is therefore, not the priority nursing action. C.INCORRECT: It is appropriate to implement case management. However, this does not address the greatest risk to the client and is therefore, not the priority nursing action. D.INCORRECT: It is appropriate to educate the client about the use of stress management techniques. However, this does not address the greatest risk to the client and is therefore, not the priority nursing action.

The provision of optimal care for patients withdrawing from substances of abuse is facilitated by the nurse's understanding that severe morbidity and mortality are often associated with withdrawal from:

Alcohol and CNS depressants

A suicidal Jewish-American client is admitted to an in-patient psychiatric unit 2 days after the death of a parent. Which intervention must the nurse include in the care of this client?

Allow the client time to mourn the loss during this time of shiva.

The nurse is reviewing orders given for a patient with depression. Which order should the nurse question?

An SSRI given initially with an MAOI

A client expresses frustration and hostility toward the nursing staff regarding the lack of care his or her recently deceased parent received. Which stage of grief is this?

Anger

Which symptom is an example of an affective alteration exhibited by clients diagnosed with severe depression?

Apathy

When interviewing with a patient who is intoxicated from alcohol, it is useful to first:

Ask what drugs other than alcohol the patient has recently used

A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse's priority intervention?

Assess vital signs, and complete physical assessment.

You are discharging Vanessa, a 30 year old victim of domestic violence, from the emergency department. She has sustained bruises and abrasions but no serious trauma. She is fearful that Children's services will take custody of her daughter. Her daughter has not been harmed and is safe with Vanessa's mother. Which intervention on your part is indicated?

Assist Vanessa to develop a safety plan for rapid escape should abuse happen again..

The nurse is planning care for a patient with depression who will be discharged to home soon. What aspect of teaching should be priority on the nurse's discharge plan of care?

Awareness of symptoms that increase depression.

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following is an expected finding? (Select all that apply.) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

B, D, E

A nurse is preparing a community education seminar about family violence. When discussing the types of violence, the nurse should include which of the following? A.Refusing to pay bills for a dependant, even when funds are available, is neglect. B.Intentionally causing an older adult to fall is an example of physical violence. C.Striking an intimate partner is an example of sexual violence. D.Failure to provide a stimulating environment for normal development is emotional abuse.

B.CORRECT: Physical violence occurs when physical pain or harm is directed toward another individual. A.INCORRECT: Refusing to pay bills for a dependant is economic maltreatment, rather than neglect. C.INCORRECT: Striking an intimate partner or other individual is an example of physical, rather than sexual, violence. Sexual violence occurs when sexual contact takes place without consent. D.INCORRECT: Failure to provide a stimulating environment for normal development is neglect, rather than emotional abuse.

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply.) A.Sunken fontanelles B.Respiratory distress C.Retinal hemorrhage D.Altered level of consciousness E.An increase in head circumference

B.CORRECT: Respiratory distress is an expected finding of shaken baby syndrome. C.CORRECT: Retinal hemorrhage is an expected finding of shaken baby syndrome. D.CORRECT: An altered level of consciousness is an expected finding of shaken baby syndrome due to intracranial trauma or hemorrhage. E.CORRECT: An increase in head circumference is an expected finding of shaken baby syndrome. A.INCORRECT: Bulging, rather than sunken, fontanelles are an expected finding of shaken baby syndrome.

A nurse working in an emergency department is assessing a child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse? (Select all that apply.) A.Abrasions on knees B.Round burn marks on forearms C.Mismatched clothing D.Abdominal rebound tenderness E.Areas of ecchymosis on torso

B.CORRECT: Round burn marks anywhere on the child's body can indicate cigarette burns and should alert the nurse to possible abuse. CORRECT: Areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse. A.INCORRECT: Minor injuries on the arms and legs, such as abrasions, are common in this age group. C.INCORRECT: Mismatched clothing is consistent with the child's developmental age. D.INCORRECT: Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse.E.

A client is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms?

Became irritable and agitated on walking.

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide (Librium) B. Bupropion (Zyban) C. Disulfiram (Antuse) D. Carbamazepine (Tegretol)

C

A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect. B. Older adults commonly use rationalization to cope with a substance use disorder. C. Older adults are at a higher risk for substance use following retirement. D. Older adults develop substance use to mask signs of dementia.

C

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following is the priority nursing intervention? A. Orient the client frequently to time, place, and person. B. Offer fluids and nourishing diet as tolerated. C. Implement seizure precautions. D. Encourage participation in group therapy sessions.

C

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates a need for further teaching? A. "We need to understand that she is not responsible for her disorder." B. "Eliminating any codependent behavior will promote her recovery." C. "She should participate in an Al-Anon group to help her recover." D. "The primary goal of her treatment is abstinence from substance use."

C

4. A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following is an appropriate response by the nurse? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do feel that you should not have been alone on the street at night?"

C. CORRECT: This response uses the therapeutic communication technique of restating, which promotes reflection and verbalization of feelings.

3. A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements indicates the need for further teaching? A. "I will administer prophylactic treatment for sexually transmitted infections like chlamydia." B. "I need to obtain informed consent before the sexual assault nurse examiner obtains forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D. "I should perform a self-assessment before caring for a client who has been raped."

C. CORRECT: This statement requires further teaching. Manifestations of rape-trauma syndrome are similar to posttraumatic stress disorder rather than bipolar disorder.

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates a need for further teaching? A."A criminal history increases the risk for violence between strangers." B."Substance use disorder increases the risk for violence." C."Entering an intimate relationship increases the risk for violence." D."Pregnancy increases the risk for violence toward the intimate partner."

C.CORRECT: This statement requires further teaching. Victims are at the greatest risk for violence when they try to leave the relationship. A.INCORRECT: This statement does not require further teaching. A past history of violence or criminal activity is a common risk factor for violence between strangers. B.INCORRECT: This statement does not require further teaching. Substance use disorder increases the risk for violence. D.INCORRECT: This statement does not require further teaching. Pregnancy tends to increase the likelihood of violence toward the intimate partner

A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority?

Calmly redirect and remove the client from the milieu.

For assessment purposes, the nurse should identify the body system most at risk for decompensation during a severe manic episode as:

Cardiac

A client newly admitted to an in-patient psychiatric unit who is experiencing a manic episode. The client's a nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client?

Chicken fingers and French fries.

What charting entry most accurately documents a clients mood?

Client rates mood 2 out of 10

A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disorder. Which student statement indicates that learning has occurred?

Clients diagnosed with bipolar II disorder experience recurrent bouts of depression with episodic occurrences of hypomania.

Ashley is a 21 year old college student who was sexually assaulted at a party. She was seen in the local emergency department and referred for counseling after being diagnosed by the provider on call as having acute stress disorder. Which of the following treatment modalities would you expect to see used in therapy with Ashley?

Cognitive-behavioral therapy

You are caring for Mick, a 32-year old patient with chemical addiction who will soon be preparing for discharge. A principle of counseling interventions that should be observed when caring for a patient with chemical addiction is to:

Communicate that relapse are always possible.

A client denying suicidal ideations comes into the emergency department complaining about insomnia, irritability, anorexia, and depressed mood. Which intervention would the nurse implement first?

Complete a thorough physical assessment including lab tests

2. A nurse is assessing a client who is the victim of sexual assault. Which of the following findings indicate the client is experiencing an initial impact reaction of rape-trauma syndrome? (Select all that apply.) A. Genitourinary soreness from the assault B. Difficulties with low self-esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions

D E

5. A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates the need for further teaching? A. "Rape is a crime of aggression." B. "Acquaintance rape often involves alcohol." C. "Both men and women can be victims of rape." D. "The majority of rapists are unknown to the victims."

D. CORRECT: This statement requires further teaching. The majority of rapists are known to the victims.

A client notifies a staff member of current suicidal ideations. Which intervention by the nurse would take priority

Determine if the client has a specific plan to commit suicide.

A client diagnosed with major depressive disorder is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse prioritize?

Discuss with the client and family expected short-term memory loss.

A client diagnosed with cyclothymia is newly admitted to an in-patient psychiatric unit. The client has a history of irritability and grandiosity and is currently sleeping 2 hours a night. Which nursing diagnoses takes priority?

Disturbed sleep patterns R / T agitation.

A client diagnosed with bipolar I disorder experienced an acute manic episode and was admitted to the in-patient psychiatric unit. The client is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply.

Financial and legal assistance Crisis hotline Individual psychotherapy Support groups Family education groups

A client diagnosed with major depressive disorder has a nursing diagnosis of low self-esteem R / T negative view of self. Which cognitive intervention by the nurse would be appropriate to deal with this client's problem?

Focus on strengths and accomplishments to minimize failures.

During an intake assessment, which client statement is evidence of the etiology of major depressive disorder from an object-loss theory perspective?

I don't know about my biological family I was in foster care as an infant

Which statement about the development of bipolar disorder is from a biochemicl perspective?

In bipolar disorder, there may be possible alterations in normal electrolyte transfers

A client diagnosed with major depressive disorder is prescribed phenelzine (Nardil). Which teaching should the nurse prioritize?

Instruct the client and family about the many food-drug and drug-drug interactions.

A client is admitted to an inpatient pscyh unit with a dx of major depressive disorder. Which of the following would the nurse expect to assess? Select all:

Loss of interest Change in body weight Psychomotor retardation Insomnia/hypersomnia

You are caring for Susannah, a 29 year old who has been diagnosed with dissociative identity disorder. She was recently hospitalized after coming to the emergency room with deep cuts on her arms with no memory of how this occurred. The priority nursing intervention for Susannah is:

Maintain 1:1 observation

Which intervention takes priority when working with newly admitted clients experiencing suicidal ideations

Monitor the client at close, but irregular, intervals

Which client statement is evidence of the etiology of major depressive disorder from a genetic perspective?

My maternal grandmother was diagnosed with bipolar affective disorder

Nick, a construction workers, is on duty when a nearly completed wall suddenly falls, crushing a number of co-workers. Although badly shaken initially, he seemed to be coping well. About two weeks after the tragedy he begins to experience tremors, nightmares, and periods during which he feels numb or detached from his environment. He finds himself frequently thinking about the tragedy and feeling guilty that he was spared while many others died. Which statement about the situation is most accurate?

Nick has acute stress disorder and will benefit from antianxiety medication

Which nursing charting entry is documentation of a behavioral symptom of mania?

Pacing halls throughout the day. Exhibits poor impulse control.

As you evaluate a patient's progress which treatment outcome would indicate a poor general prognosis for long term recovery from substance abuse?

Patient demonstrates positive expectations for ongoing drug use.

Nadia has been diagnosed with bipolar disorder. Which is an outcome for Nadia in the continuation of treatment phase of bipolar disorder?

Patient will adhere to medication regimen

A medication teaching plan for a patient receiving lithium should include:

Periodic monitoring of renal and thyroid function

You are caring for Leah a 26 y/o patient who has been abusing CNS stimulants. Which statement provides a basis for planning care for patient who abuses CNS stimulants?

Post withdrawal symptoms include fatigue and depression

A client's outcome states, "The client will make a plan to take control of one life situation by discharge." Which nursing diagnosis documents the client's problem that this outcome addresses?

Powerlessness

A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation?

Privately discuss with the client the inappropriateness of provocative dress during hospitalization.

Mindy is the nurse caring for Caitlin, who was raped the night before. Caitlin is considering the morning-after pill to prevent possible pregnancy that may have resulted from the rape. Caitlin is concerned and states that she does not believe in abortion. Which of the following is the most appropriate action Mindy could take in this situation?

Provide Caitlin with medication education

The nurse caring for a patient who exhibits disorganized thinking and delusions. The patient repeatedly states, "I hear voices of aliens trying to contact me." The nurse should recognize this presentation as which types of major depressive disorder (major depression)?

Psychotic

Tara, a 19 year old freshman college student, arrives for a follow-up appointment at the mental health clinic where you work. She has previously been seen in the clinic for crisis intervention three weeks ago after being raped. Tara states, "My mom says I was asking for trouble because of the way I was dressed at the party. She says when girls dress so sexy, men can't help themselves." Your response is guided by the knowledge that:

Rape is an act of violence, aggression, and power, not an expression of sexual needs.

A client plans and follows thru with the wake and buriall of a child lost in an auto accident.

Restitution

Which nursing diagnosis takes priority for a client immediately after electroconvulsive therapy (ECT)?

Risk for injury r/t altered mental status

A newly admitted client has been diagnosed with major depressive disorder. Which nursing diagnosis takes priority?

Risk for self directed violence r/t depressed mood

A client diagnosed with major depressive disorder has been newly admitted to an in-patient psychiatric unit. The client has a history of two suicide attempts by hanging. Which nursing diagnosis takes priority?

Risk for suicide R / T history of attempts

A client diagnosed with bipolar I disorder and experiencing a manic episode is newly admitted to the in-patient psychiatric unit. Which nursing diagnosis is a priority at this time?

Risk for violence: other-directed R / T poor impulse control.

A newly admitted client diagnosed with major depressive disorder isolates self in room and stares out the window. Which nursing intervention would be the most appropriate to implement initially, when establishing a nurse-client relationship?

Sit with the client and offer self frequently.

Which nursing diagnosis supports the psychoanalytic theory of development of major depressive disorder

Social isolation r/t self directed anger

A client has a nursing diagnosis of dysfunctional grieving R / T loss of a job AEB inability to seek employment because of sad mood. Which would support a resolution of this client's problem?

The client recognizes and accepts the role he or she played in the loss of the job.

A client diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R / T biochemical alterations. Based on this diagnosis, which outcome would be appropriate?

The client will distinguish reality from delusions by day 6

A client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R / T egocentrism. Which short-term outcome is an appropriate expectation for this client problem?

The client will have an appropriate 1:1 interaction with a peer by day 4

A client has a nursing diagnosis of risk for suicide R / T a past suicide attempt. Which outcome, based on this diagnosis, would the nurse prioritize?

The client will remain free from injury throughout hospitalization.

A client admitted with major depressive disorder has a nursing diagnosis of ineffective sleep pattern R / T aches and pains. Which is an appropriate short-term outcome for this client

The client will sleep 6 to 8 hours at night by day 5

An appropriate expected outcome in family therapy regarding the perpetrator of abuse would be:

The perpetrator will recognize destructive patterns of behavior and learn alternate responses

A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the client's use of grandiosity. Which is the rationale for this nurse's action?

Understanding the reason behind a behavior would assist the nurse to accept and relate to the client, not the behavior.

A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R / T extreme hyperactivity. Which nursing intervention is appropriate?

Use PRN antipsychotic medications as ordered by the physician.

A major principle the nurse should observe when communicating with a patient experiencing elated mood is to:

Use calm, firm approach

Which symptom related to communication is likely to be present in a patient experiencing mania?

Verbosity

You are caring for Connor, an 8 year old boy who had been diagnosed with reactive attachment disorder. Which of the following nursing outcomes would be the most appropriate to achieve?

Writes or draws feelings in a journal

Josephina was raped 6 months ago. Which symptom(s) should you anticipate for long-term successful outcomes? (select all that apply)

a. Evidence of comfort in relationships c. Recognition of the right to be protected from abuse f. Anxiety being replaced by calmness g. Absence of phobia of being alone

Perpetrators of domestic violence tend to: (select all that apply)

a. Have relatively poor social skills and to have grown up with poor role models. b. Believe that, if male, should be dominant and in charge in relationships. d. Be controlling and willing to use force to maintain their power in relationships e. Prevent their mates from having relationships and activities outside the family

Nathan, a nursing student, is assigned to care for Shawna, who is recovering from injuries received during an episode of domestic violence, the third such assault for which she has received treatment. Nathan left home at age 17 to escape an abusive father. Which statement about Nathan's situation are accurate? (select all that apply)

b. His personal experiences give him special insight into the needs of this patient c. His experiences are likely to make him more empathetic towards victims. e. He may experience overwhelming emotions as a result of caring for abuse victims. f. He would likely benefit from clinical supervision related to caring for abuse victims

Which symptom is an example of physiological alterations exhibited by clients diag- nosed with moderate depression?

decreased libido