Exam 2 Book Ch. 35 and 36

Ch. 35 A battered woman presents to the emergency department with multiple cuts and abrasions. Her right eye is swollen shut. She says that her husband did this to her. What is the priority nursing intervention? A. Tending to the immediate care of her wounds B. Providing her with information about a safe place to stay C. Administering the prn tranquilizer ordered by the physician D. Explaining how she may go about bringing charges against her husband

A

Ch. 35 A school nurse notices bruises and scars on a child's body. The nurse suspects that the child is being physically abused. How should the nurse proceed with this information? A. As a health-care worker, report the suspicion to child protective services. B. Check the child again in a week and see if there are any new bruises. C. Meet with the child's parents and ask them how she got the bruises. D. Initiate paperwork to have the child placed in foster care.

A

Ch. 36 The physician orders trazadone (Desyrel), 150 mg to be taken at bedtime, for Mrs. W., a 78-year-old widow with depression. Which of the following statements about this medication would be appropriate for the home health nurse to make in teaching Mrs. W. about trazadone? A. "You may feel dizzy when you stand up, so go slowly when you get up from sitting or lying down." B. "You must not eat chocolate while you are taking this medicine." C. "We will need to draw a sample of blood to send to the lab every month while you are on this medication." D. "If you don't feel better right away with this medicine, the doctor can order a different kind for you."

A

Ch. 36 Which of the following represents a nursing intervention at the primary level of prevention? A. Teaching a class in parent effectiveness training B.Leading a group of adolescents in drug rehabilitation C. Referring a married couple for sex therapy D. Leading a support group for battered women

A

Ch. 36 Which of the following represents a nursing intervention at the tertiary level of prevention? A. Serving as case manager for a mentally ill homeless client B. Leading a support group for newly retired men C. Teaching prepared childbirth classes D. Caring for a depressed widow in the hospital

A

Ch. 36 Which of the following issues have been identified as contributing to the rise in the population of those who are homeless? (Select all that apply.) A. Poverty B. Lack of affordable health care C. Substance abuse D. Severe and persistent mental illness E. Growth in the number of family members living together

A, B, C, D

Ch. 35 A young woman who has just undergone a sexual assault is brought into the emergency department by a friend. What is the priority nursing intervention? A. Help her to bathe and clean herself up. B. Provide physical and emotional support during evidence collection. C. Provide her with a written list of community resources for survivors of rape. D. Discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.

B

Ch. 35 Jana, age 5, is sent to the school nurse's office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that Jana has numerous bruises on her arms and torso in various stages of healing. She also notices some small scars. Jana's abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse suspects that: A. Jana is experiencing physical and sexual abuse. B. Jana is experiencing physical abuse and neglect. C. Jana is experiencing emotional neglect. D. Jana is experiencing sexual and emotional abuse.

B

Ch. 35 Kate is an 18-year-old freshman at the state university. She was extremely flattered when Don, a senior star football player, invited her to a party. On the way home, he parked the car in a secluded area by the lake. He became angry when she refused his sexual advances. He began to beat her and finally raped her. She tried to fight him, but his physical strength overpowered her. He dumped her in the dorm parking lot and left. The dorm supervisor rushed Kate to the emergency department. Kate says to the nurse, "It's all my fault. I shouldn't have allowed him to stop at the lake." The nurse's best response is: A. "Yes, you're right. You put yourself in a very vulnerable position when you allowed him to stop at the lake." B. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack." C. "There's no sense looking back now. Just look forward, and make sure you don't put yourself in the same situation again." D. "You'll just have to see that he is arrested so he won't do this to anyone else."

B

Ch. 35 Sharon, a woman with multiple cuts and abrasions, arrives at the emergency department with her three small children. She tells the nurse her husband inflicted the wounds. She says, "I didn't want to come. I'm really okay. He only does this when he has too much to drink. I just shouldn't have yelled at him." The best response by the nurse is: A. "How often does he drink too much?" B. "It is not your fault. You did the right thing by coming here." C. "How many times has he done this to you?" D. "He is not a good husband. You have to leave him before he kills you."

B

Ch. 36 Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to Mrs. W., a 78-year-old widow who lives alone. Mrs. W.'s primary care physician has diagnosed her as depressed. Which of the following criteria would qualify Mrs. W. for home health visits? A. Mrs. W. never learned to drive and has to depend on others for her transportation. B. Mrs. W. is physically too weak to travel without risk of injury. C. Mrs. W. refuses to seek assistance as suggested by her physician, "because I don't have a psychiatric problem." D. Mrs. W. says she would rather have home visits than go to the physician's office.

B

Ch. 36 Which of the following represents a nursing intervention at the secondary level of prevention? A. Teaching a class about menopause to middle-aged women B. Providing support in the emergency room to a rape victim C. Leading a support group for women in transition D. Making monthly visits to the home of a client with schizophrenia to ensure medication compliance

B

Ch. 35 Sharon, a woman with multiple cuts and abrasions, arrives at the emergency department with her three small children. She tells the nurse her husband inflicted the wounds. In the interview, Sharon tells the nurse, "He's been getting more and more violent lately. He's been under a lot of stress at work the last few weeks, so he drinks a lot when he gets home. He always gets mean when he drinks. I was getting scared. So I just finally told him I was going to take the kids and leave. He got furious when I said that and began beating me with his fists." With knowledge about the cycle of battering, what does this situation represent? A. Phase I. Sharon was desperately trying to stay out of his way and keep everything calm. B. Phase I. A minor battering incident for which Sharon assumes all the blame. C. Phase II. The acute battering incident that Sharon provoked with her threat to leave. D. Phase III. The honeymoon phase where the husband believes that he has "taught her a lesson and she won't act up again."

C

Ch. 36 Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to Mrs. W., a 78-year-old widow who lives alone. Mrs. W.'s primary care physician has diagnosed her as depressed. Which of these potential problems is a priority to evaluate for during the first home visit? A. Complicated grieving B. Social isolation C. Risk for injury D. Sleep pattern disturbance

C

Ch. 36 John, a homeless person, has just come to live in the shelter. The shelter nurse is assigned to his care. Which of the following is a priority intervention on the part of the nurse? A. Referring John to a social worker B. Developing a plan of care for John C. Conducting a behavioral and needs assessment on John D. Helping John apply for Social Security benefits

C

Ch. 35 A school nurse notices bruises and scars on a child's body, but the child refuses to say how she received them. Another way in which the nurse can get information from the child is to: A. Have her evaluated by the school psychologist. B. Tell her she may select a "treat" from the treat box (e.g., sucker, balloon, junk jewelry) if she answers the nurse's questions. C. Explain to her that if she answers the questions, she may stay in the nurse's office and not have to go back to class. D. Use a "family" of dolls to role-play the child's family with her.

D

Ch. 35 A woman who has a long history of being battered by her husband is staying at the woman's shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. The best response by the nurse to the woman's decision is: A. "I just can't believe you have decided to go back to that horrible man." B. "I'm just afraid he will kill you or the children when you go back." C. "What makes you think things have changed with him?" D. "I hope you have made the right decision. Call this number if you need help."

D

Ch. 35 A woman who was sexually assaulted 6 months ago by a male acquaintance has been attending a support group for survivors of rape. From this group, she has learned that the most likely reason the man raped her was that: A. Because he had been drinking, he was not in control of his actions. B. He had not had sexual relations with a girl in many months. C. He was predisposed to become a rapist by virtue of the poverty conditions under which he was reared. D. He was expressing power and dominance by means of sexual aggression and violence.

D

Ch. 36 John, a homeless person, has a history of schizophrenia and nonadherence to his medication regimen. Which of the following medications might be the best choice for John? A. Haldol B. Navane C. Lithium carbonate D. Prolixin decanoate

D

Ch. 36 Mrs. W., a 78-year-old depressed widow, says to her home health nurse, "What's the use? I don't have anything to live for anymore." Which is the best response on the part of the nurse? A. "Of course you do, Mrs. W. Why would you say such a thing?" B. "You seem so sad. I'm going to do my best to cheer you up." C. "Let's talk about why you are feeling this way." "Are you having thoughts about harming yourself in any way?"

D