MH Exam 4 , MH EXAM 4 - ATI, Dementia & Delirium Questions
A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response.
"Are you thinking of suicide"
An obviously pregnant woman appears for her first prenatal visit. She reports a headache and generalized abdominal pain which has persisted over the past couple months. Which question should the nurse prioritize after determining the client is approximately 24 weeks' gestation, appears nervous, and is reluctant to have a full physical assessment?
"Do you feel safe at home?"
Which statement made by a male client who has a history of perpetrating intimate partner violence reflects a known factor that is characteristic of this behavior?
"My classmates always called me a bully."
A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely?
"She wanted the sex"
The nurse is educating women on characteristics of perpetrators of intimate partner violence. What characteristics of abusers will the nurse include in the teaching? Select all that apply.
-A history of oxycodone and diazepam use disorder -10 different employers in the past 18 months -Arrested twice in the last year -Dominates the control in personal and social situations
A nurse is caring for a pregnant client and discovers signs of bruises near her neck. On questioning, the nurse learns that the bruises were caused by her spouse. The client tells the nurse that the spouse had stopped hitting her some time ago, and that this was the first time during the pregnancy that she was assaulted. The client blames herself because she admits to not paying enough attention to her spouse. Which facts about intimate partner violence during pregnancy should the nurse tell the client to convince her that the violence was not her fault? Select all that apply.
-Intimate partner violence is a result of resentment toward the interference of the growing fetus and change in the woman's shape. -Intimate partner violence is a result of the perception of the partner that the baby will be a competitor after he or she is born. -Intimate partner violence is a result of insecurity and jealousy of the pregnancy and the responsibilities it brings.
A victim of rape is exhibiting symptoms of posttraumatic stress disorder (PTSD) which the nurse interprets as indicative of intrusion. Which symptoms would the client be exhibiting? Select all that apply.
-Nightmares -Recurrent thoughts -Flashbacks
A group of nursing students are preparing a talk on violence against women and how to prevent it. They want to list characteristics of perpetrators of intimate partner violence and should include which characteristics? Select all that apply.
-Substance and/or alcohol use disorder -Negative affect (hostility and depression) -History of childhood abuse -Current unemployment -History of antisocial behavior
A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following statements should the nurse include in the teaching? ✔ A. "Donepezil can improve cognitive functioning during the earlier stages of the disease." B. "Donepezil cures the disease process if started at the first recognition of dementia." C. "Donepezil provides long-term reversal of memory loss in the last phase of the disease." D. "Donepezil accelerates the breakdown of acetylcholine within the client's brain."
A. "Donepezil can improve cognitive functioning during the earlier stages of the disease."
ATI: A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following statements should the nurse include in the teaching? A. "Donepezil can improve cognitive functioning during the earlier stages of the disease." B. "Donepezil cures the disease process if started at the first recognition of dementia." C. "Donepezil provides long-term reversal of memory loss in the last phase of the disease." D. "Donepezil accelerates the breakdown of acetylcholine within the client's brain."
A. "Donepezil can improve cognitive functioning during the earlier stages of the disease."
A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory? A. "In what year did you graduate from high school?" B. "What is your favorite childhood memory?" C. "What did you have for supper yesterday?" D. "What is today's date?"
A. "In what year did you graduate from high school?"
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client B. Ask open-ended questions C. Limit visitors to 3 at a time D. Use different words if the client does not understand a statement
A. Add gestures when speaking with the client
A nurse in an emergency department is teaching newly licensed nurses about planning interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis
A. Determine if the client is experiencing thoughts of self-harm
A nurse in an emergency department is teaching newly licensed nurses about planning interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis
A. Determine if the client is experiencing thoughts of self-harm
If you have a victim of intimate partner violence, know nursing dx for that patient A nurse is caring for a client who presents with a fractured wrist. The nurse suspects intimate partner violence. Which of the following interventions is the nurse's priority? A. Help the client develop a safety plan B. Teach the client empowerment skills C. Provide information about a support group for intimate partner abuse D. Make a follow-up appointment with the primary provider
A. Help the client develop a safety plan
A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? A. Request a prescription for an antianxiety medication B. Provide the client with a stimulating activity prior to bedtime C. Dim the lights in the client's room at night D. Encourage the client to make decisions about her daily routine
A. Request a prescription for an antianxiety medication
Which family scenario presents the greatest risk for family violence?
An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child
A nurse is caring for a pregnant woman who has multiple bruises in varying stages across her body. Which is the priority nursing action?
Ask if anyone at home has hit or hurt her.
A nurse is caring for a client who is a sexual assault survivor. The client says, "I feel so humiliated. I don't want anyone to know what happened to me." Which of the following responses should the nurse make? A. "You will be just fine. You'll see." B. "Are you saying that you are fearful of what others will think?" C. "This is a normal feeling after what happened to you." D. "The best thing for you to do is to put this event out of your mind and think positive thoughts."
B. "Are you saying that you are fearful of what others will think?"
A nurse is caring for a client who is a sexual assault survivor. The client says, "I feel so humiliated. I don't want anyone to know what happened to me." Which of the following responses should the nurse make? A. "You will be just fine. You'll see." B. "Are you saying that you are fearful of what others will think?" C. "This is a normal feeling after what happened to you." D. "The best thing for you to do is to put this event out of your mind and think positive thoughts."
B. "Are you saying that you are fearful of what others will think?"
A nurse is teaching about taking donepezil with a client who was recently diagnosed with early Alzheimer's disease. Which of the following instructions should the nurse include in the teaching? A. "You should chew the medication thoroughly prior to swallowing." B. "You should take this medication late in the evening." C. "You should take this medication with food." D. "If you miss taking a dose for a day, take 2 doses the following day."
B. "You should take this medication late in the evening."
A nurse is teaching about taking donepezil with a client who was recently diagnosed with early Alzheimer's disease. Which of the following instructions should the nurse include in the teaching? A. "You should chew the medication thoroughly prior to swallowing." B. "You should take this medication late in the evening." C. "You should take this medication with food." D. "If you miss taking a dose for a day, take 2 doses the following day."
B. "You should take this medication late in the evening."
A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's daughter visited on the day in question. Which of the following cognitive impairments is the client demonstrating? A. Perseveration B. Confabulation C. Apraxia D. Agnosia
B. Confabulation
Which communication pattern is defined as confabulation? A. The flow of thoughts is interrupted. B. Imagination is used to fill in memory gaps. C. Speech flits from one topic to another. D. Statements are too loose to understand.
B. Imagination is used to fill in memory gaps.
Which communication pattern is defined as confabulation? A. The flow of thoughts is interrupted. B. Imagination is used to fill in memory gaps. C. Speech flits from one topic to another. D. Statements are too loose to understand.
B. Imagination is used to fill in memory gaps.
: A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgment C. Rapid change in personality D. Disturbances in perception
B. Impaired judgment
A nurse is caring for a client who has acute delirium. Which of the following findings should the nurse expect? A. Progressive deterioration of cognitive function B. Rapid fluctuation in level of consciousness C. Loss of language ability D. Absence of contributing factors to pinpoint the cause of delirium
B. Rapid fluctuation in level of consciousness
A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The primary healthcare provider prescribes 0.25 mg of alprazolam for agitation. The nurse will administer this medication when what event occurs? A. The client's crying increases. B. The client requests something to calm her. C. The nurse determines a need to reduce her anxiety. D. The primary healthcare provider is getting ready to perform a vaginal examination
B. The client requests something to calm her.
An appropriate expected outcome in individual therapy regarding the perpetrator of abuse would be: A. A decrease in family interaction so that there are fewer opportunities for abuse to occur. B. The perpetrator will recognize destructive patterns of behavior and learn alternate responses. C. The perpetrator will no longer live with the family but have supervised contact while undergoing intensive inpatient therapy. D. A triad of treatment modalities, including medication, counseling, and role-playing opportunities.
B. The perpetrator will recognize destructive patterns of behavior and learn alternate responses.
Nurse in ED taking family history from family accompanying child w suspicious traumatic injuries. The nurse should do what?
Be open, concerned and honest.
A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing these injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make? A. "Aren't you worried about the safety of your children?" B. "Can you identify which of your behaviors provoke your partner?" C. "The next time this occurs, what could you do to ensure your safety?" D. "You need to remove yourself and your children from an abusive situation."
C. "The next time this occurs, what could you do to ensure your safety?"
Which factor would precipitate a client's use of confabulation? A. Ideas of grandeur B. Need for attention C. Marked memory loss D. Difficulty in accepting the diagnosis
C. Marked memory loss
Which factor would precipitate a client's use of confabulation? A. Ideas of grandeur B. Need for attention C. Marked memory loss D. Difficulty in accepting the diagnosis
C. Marked memory loss
A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? A. Flat affect B. Refusal to accept help from others C. Report of intense guilt D. Denial of the sexual assault
C. Report of intense guilt
A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? A. Flat affect B. Refusal to accept help from others C. Report of intense guilt D. Denial of the sexual assault
C. Report of intense guilt
A nurse in an emergency department is caring for a client who states, "I tripped over the dog again." The nurse notes the client has multiple lacerations and ecchymoses and sees in the client's medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take? A. Ask the client what she believes she did to deserve being physically abused B. Avoid documenting subjective verbatim statements from the client regarding injuries C. Talk to the client about making a safety plan D. Explain the cycle of violence to the client
C. Talk to the client about making a safety plan
The nurse is teaching the family caregivers how to communicate with a patient who has dementia. What communication strategy can improve orientation of the patient?
Call the person by name every time you see him or her
During morning care, an AP asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response?
Confabulation
When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. "I don't know." b. "Is that the right answer?" c. "Wait, let me think about that." d. "Who are those people over there?"
Correct Answer: A Rationale: Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.
The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.
Correct Answer: A Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read.
Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer's disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective? a. The patient has less agitation. b. The patient is dressed appropriately. c. The patient is able to swallow a pill. d. The patient's speech is clearer.
Correct Answer: A Rationale: Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioral problems associated with AD. The other improvements might occur with cholinesterase inhibitors.
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown
Correct Answer: A Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.
Correct Answer: B Rationale: The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has.
When teaching the spouse of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD can be made only when other causes of dementia have been ruled out. c. new drugs have been shown to reverse AD dramatically in some patients. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.
Correct Answer: B Rationale: The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well.
During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Move the patient to a quieter room at night. b. Open the blinds in the patient's room and provide frequent activities. c. Have the patient take a brief mid-morning nap. d. Provide hourly orientation to time of day.
Correct Answer: B Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. have a close family member remain with the patient and provide reassurance. b. assign a staff member to stay with the patient and offer frequent reorientation. c. ask the health care provider about ordering an antipsychotic drug. d. secure the patient in bed with a soft chest restraint.
Correct Answer: B Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.
3. When administering a mental status examination to a patient with delirium, the nurse should a. give the examination when the patient is well-rested. b. reorient the patient as needed during the examination. c. choose a place without distracting environmental stimuli. d. medicate the patient first to reduce anxiety.
Correct Answer: C Rationale: Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.
A home-health patient with Alzheimer's disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Setting the medications up weekly in a medication box b. Calling the patient daily with a reminder to take the medication c. Having the patient's spouse administer the medication d. Posting reminders to take the medications in the patient's house
Correct Answer: C Rationale: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications.
A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. administer the PRN dose of lorazepam (Ativan). b. reorient the patient to time and place. c. assess the patient for anything that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.
Correct Answer: C Rationale: Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.
Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.
Correct Answer: C Rationale: Parkinson's disease and depression are both potentially reversible conditions, and the patient's symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient's condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient's other conditions.
When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d. Have the family bring in familiar items from the patient's home.
Correct Answer: C Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. Use of "why" questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.
A patient with Alzheimer's disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, "I am just exhausted from the constant care and worry. We don't have any children and we can't afford a nursing home. I don't know what to do." The most appropriate nursing diagnosis for the spouse is a. anxiety related to limited financial resources. b. ineffective health maintenance related to stress. c. caregiver role strain related to limited resources for caregiving. d. social isolation related to unrelieved caregiving responsibilities.
Correct Answer: C Rationale: The spouse's statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse's problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation.
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do have any feelings of sadness?" c. "What day of the week is it today?" d. "How positive is your self-image?"
Correct Answer: C Rationale: This question tests the patient's orientation to time, which is decreased in early Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.
A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.
Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.
Correct Answer: D Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia. Cognitive Level: Application Text Reference: p. 1562 Nursing Process: Assessment NCLEX: Physiological Integrity
A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence? A. "Last night my partner beat me worse than ever before." B. "It'll be easier just to make my partner mad and get the violence over with." C. "I believe my partner is remorseful and won't hurt me again." D. "I only got shoved a little bit, and it was my fault for coming home late."
D. "I only got shoved a little bit, and it was my fault for coming home late."
A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of this medication every 72 hr C. Offer the client a PRN NSAID while taking this medication D. Administer the medication at bedtime
D. Administer the medication at bedtime
A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of this medication every 72 hr C. Offer the client a PRN NSAID while taking this medication D. Administer the medication at bedtime
D. Administer the medication at bedtime
An older adult seems to make up stories to fill in for memory lapses. Which behavior is the client displaying? A. Lying B. Denying C. Fantasizing D. Confabulating
D. Confabulating
A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take? A. Obtain a PRN prescription for restraints from the client's provider. B. Visually observe the client every 10 min until restraints are removed. C. Ensure 3 fingers can fit between the restraint and the client's wrist. D. Document the client's behavior every 15 min while restraints are in place.
D. Document the client's behavior every 15 min while restraints are in place.
A 16-year-old girl is seen in an emergency department following a rape. The management of a rape victim should be directed primarily toward:
Decreasing guilt and increasing self-esteem.
When elderly pt brought to ED by family members reporting fall, nurse becomes suspicious that patient is suffering from what?
Denial of abuse based on fear of possible removal from family
Female come to Ed w broken wrists and severe bruises from beating from husband. She states she doesn't want to leave the relationship at this time. What's the nurses most appropriate response?
Develop safety plan.
The nurse is helping the family of a client who has experienced a rape provide appropriate support. Which information should the nurse provide if the client is in the disorganizational phase of recovery?
Feelings of guilt and shame are characteristic.
When working with rape victims, what is the focus of initial care?
Helping the victim feel safe
Pt diagnosed w stage 1 mild Alzheimer's disease tires easily and prefers to stay home over attending social activities. Spouse does the grocery shopping as pt can't remember what to buy. Which nursing diagnosis applies to the pt at this time?
Impaired memory
A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will:
Name two community resources that can be contacted.
An 18-month-old client is scheduled for a minor surgical procedure. The client has numerous large bruises of different stages over the back and buttocks. The mother states that the child must have fallen down while playing alone but cannot provide specific information. How should the nurse evaluate this situation? a. Possible child abuse b. Indications of tissue fragility c. Normal findings in an 18-month-old d. Immature parenting
Possible child abuse
A pregnant woman comes to the clinic with a head injury. She tells the nurse that her partner came home drunk and she made him angry by not having dinner ready. He lashed out, she got in the way, and her head hit the corner on the table. What action should the nurse take in this situation?
Provide the client with contact information for a 24-hour shelter and social worker on discharge.
Five-year-old girl brought into clinic w s/s of UTI...nurse assessment reveals wounds in genital & rectal area. What's the nurses first priority?
Report suspected sexual abuse to protective services (CPS)
Pregnant female comes to ED w bruises on arms and abdomen after fight w bf. Nurse will determine which of the following to be priority for teaching w client?
Risk of pregnancy complications caused by the abuse.
A pregnant female comes to the emergency department with bruises on her arms and abdomen after a fight with her boyfriend. What is most important for the nurse to address when teaching this client?
Risks of pregnancy complications caused by abuse
A nurse works with a person who was raped 4 years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person?
Survivor
The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention?
Use accepting, nursing, and empathetic communication techniques
How to speak to someone with Alzheimer's? Talk short sentences, slowly. Which of the following interventions should be incorporated into care for pt with Alzheimer's disease?
When talking w patients, use short simple words and phrases.
A nurse is teaching a class on domestic violence to high school students. Which statement by a student would indicate to the nurse that further teaching is needed? a. "If you are educated and have money, abuse does not happen." b. "Abusers are often excessively jealous and possessive." c. "The abuser will often apologize and promise to stop." d. "Violence often begins in a dating relationship."
a. "If you are educated and have money, abuse does not happen."
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 they, if male, should be dominant and in charge in relationships. c. Force their mates to work and expect them to handle the financial decisions. 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.
a. Have relatively poor social skills and to have grown up with poor role models. b. Believe they, 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.
A 15-year-old female student visits the school nurse's office asking about date rape and pregnancy. She confides that her boyfriend forced her to have sex against her will. What would be the most appropriate initial intervention by the nurse? a. Administer a pregnancy test. b. Identify the student's immediate concerns and feelings. c. Teach safe sex practices. d. Teach methods of birth control.
b. Identify the student's immediate concerns and feelings.
A nurse works with a person who was raped four years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator
b. Survivor
A five-year-old child has been removed from the home because of sexual abuse by the stepfather. What information should the nurse include when teaching the child's mother about possible consequences the child might experience? a. Because the abuser was someone well known by the child, the situation will be less traumatic for the child. b. The child is at current risk for developing depression and will remain so in the future. c. Since the child was removed from the home at an early age, no long-term consequences are expected. d. Once an adult, the child should be counseled not to have children, as the child will become an abuser.
b. The child is at current risk for developing depression and will remain so in the future.
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do have any feelings of sadness?" c. "What day of the week is it today?" d. "How positive is your self-image?"
c. "What day of the week is it today?"
A five-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse's assessment reveals bruises in the child's genital and rectal areas. The mother reports that she had left the little girl with her boyfriend the night before. Which action should be the nurse's first priority with this client? a. Assess the child for other health problems. b. Obtain a urine sample to confirm a UTI. c. Report suspected sexual abuse to protective services. d. Teach the mother about symptoms of UTI.
c. Report suspected sexual abuse to protective services.
An adult survivor of child abuse states, "Why couldn't I make him stop the abuse? If I were a stronger person, I might have been able to make him stop. Maybe it was my fault he abused me." Based on this data, which would be the most appropriate priority nursing concern? a. Social isolation b. Anxiety c. Inability of family to cope d. Chronic low self-esteem
d. Chronic low self-esteem
The nurse is counseling an extremely distressed female victim immediately after a sexual assault. What should be the nurse's most important initial intervention? a. Collect a serum specimen for pregnancy testing. b. Ask the client to provide a sample of pubic hair for the evidence kit. c. Teach the client about the risk for sexually transmitted infections. d. Reassure the victim that the sexual assault was not her fault.
d. Reassure the victim that the sexual assault was not her fault.
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.
d. The patient was oriented and alert when admitted.
