Exam #3 Questions

The nurse is conducting a lecture about abuse for high school students. Which statement should the nurse include?

"Abuse is caused by a need for power and control." Abuse is often r/t control and power, with one individual attempting to control another. Humiliation and physical injuries are quite common characteristics of physical, emotional, and sexual abuse. The different types of abuse often overlap: Both physical and sexual abuse can begin as emotional abuse.

The nurse is caring for a pt who was a victim of an assault outside the pt's home. Which question should the nurse ask in order to determine whether the patient was the victim of a simple assault or aggravated assault?

"Did the assailant use a weapon?" A simple assault is one that occurs without the use of a weapon. An aggravated assault involves the use of a weapon, such as a knife or gun. The type of assault is not determined by the number or extent of the injuries or the length of the assault.

The nurse is assessing a 5-year-old patient who is diagnosed with PTSD. The child is accompanied by both parents. Which assessment question by the nurse is most appropriate?

"Do you sleep all the way through the night?" When assessing a child who has or may have PTSD, it is helpful to use direct Qs. Assessment of younger children involves questioning the child and/or the parents about significant changes in behavior & sleeping patterns. For ex, it may be best to Q the child to determine if there has been a change in sleeping habits. Drawing a picture can often cause children to reexperience trauma. This should be used c caution in children diagnosed c PTSD. Moreover, children may not recognize when they are angry or sad.

Which statement by the nurse regarding the fatality of falls in older adults is true?

"Falls are the most common cause of multisystem trauma resulting in death.". Older adults are less likely to be injured than younger adults; however, they are more likely to have a fatal outcome. Falls are the most common cause of multisystem trauma resulting in death for older patients.

The nurse is handing a healthcare provider's sterile supplies for suturing several young people who reportedly were involved in a gang-related altercation. Which statement by the nurse shows the need for further teaching

"Gang members always lie about the cause of their injuries." Gang members may or may not report the true cause of their injuries, but it is a misconception to state that they always lie. Nurses should not have negative preconceived ideas about gangs.

Which statement most accurately describes health policy?

"Health policy includes governmental actions that affect patients' abilities to reach healthcare goals."

A child confides to the school nurse that the child's father sometimes hits the child when angry. Which reponse from the nurse is best?

"I believe you. Here's what is going to happen next." When caring for a child who is suspected of being a victim of abuse, it is important for the nurse to convey belief of the child. The nurse should not doubt or blame the child, nor should the nurse speak poorly about the abuser.

The nurse has completed teaching on the prevention of rape for a community group. Which statement by a group participant indicates that further instruction is needed?

"I feel like I am safe at night if I just run across the street to the laundromat." It is not recommended to be out on the street alone at night, even if it is to cross the street. Lifestyle alterations to prevent rape: Having knowledge and awareness about situations Paying attention to surroundings Traveling in pairs Taking self-defense classes Avoiding date-rape drugs

The nurse is speaking with a woman who has a long history of physical abuse by her spouse. The patient does not want to leave her partner at this time, and the nurse initiates teaching of a safety plan. Which patient statement indicates a need for further learning?

"I should keep my wallet and keys hidden so that he can't find them.". Part of a safety plan involves keeping the pt's wallet, purse, or keys in an easily accessible place at all times in case of the need to leave quickly & unexpectedly. teach children how to dial 911. The pt should also be able to describe the easiest escape route from all rooms in the house. If a situation were to become serious, the woman should be advised to give the spouse what he wants in an attempt to diffuse the situation.

The nurse is providing discharge teaching for a patient diagnosed with PTSD. Which patient statement indicates the need for further teaching?

"I will drink a few beers when I am anxious."Exs of pt goals: remain free from injury or harm; will report a decreased perception of anxiety. will report a reduction or cessation of nightmares. will discuss emotions related to traumatic experiences with at least one trusted mental health specialist or counseling professional. will verbalize awareness of nonpharm stress-reduction techniques.

The nurse provided discharge teaching to a patient who is recovering from a stab wound. Which patient statement indicates the need for further teaching?

"I will stop taking my antibiotic as soon as I am no longer in pain."

The nurse is caring for a pregnant patient who repeatedly presents to the clinic with multiple bruises. When asked, the patient states that she can deal with what is happening and that her spouse would never hit the baby, even though he didn't want them to have the baby. Which response by the nurse is best?

"Infants that are born out of an unwanted pregnancy are at higher risk for abuse or trauma."

A patient who sustained blunt-force trauma to the chest during a MVC asks the nurse, "Why do I need an electrocardiogram?" Which response should the nurse give?

"It will help us to rule out heart damage."

When describing a Medigap policy to an older adult patient, which statement by the nurse is most accurate?

"Medicare is a government policy that pays some of your medical bills. A Medigap policy is purchased by you privately to cover costs not covered by Medicare."

The nurse researcher is preparing a webinar about the history of nursing research. Which statement should be included?

"Membership in Sigma Theta Tau International is by invitation only to baccalaureate and graduate nursing students."

The parents of a teenager are talking with the nurse about the injuries their son sustained in a physical fight during his high school lunch hour. Which should the nurse tell them about fighting in adolescence?

"One-third of high school students will get into a physical fight at school." Factors that increase resiliency include: Strong, well-developed support system Effective coping skills Positive belief that one can survive Hope, including optimism, spiritual belief, and practical resources

The nurse case manager is reviewing Medicare coverage rules with a patient. Which patient statement indicates correct understanding of the teaching?

"Prescription drug coverage is available through Medicare." Medicare Part D offers prescription drug coverage. Part A - hospital coverage. Part B - medical insurance. Part C - Medicare advantage plans. Part D - Medicare prescription drug coverage.

The nurse is giving a presentation on the role and functions of specialty nursing practice organizations to a group of colleagues. Which statement is accurate for the nurse to include in the presentation regarding these organizations?

"Specialty nursing practice organizations advance nursing practice in the affiliated specialty area."

The staff nurse asks the nursing supervisor, "Which regulatory agency requires hospitals to have personal protective equipment (PPE) ready for us to use when we need it?" Which response is correct?

"The Occupational Safety & Health Admin" OSHA is to help employers fulfill their responsibilities to their employees r/t creating safe, healthful workplace environments & reducing or eliminating workplace hazards. OSHA standards include ensuring that employees have and use PPE when required for safety & health

A patient in a support group for rape survivors states, "I do not understand why I need to come to this group." Which response by the nurse is most appropriate?

"The group provides a safe place to discuss your own individual experience." Rape victims attending group meetings are able to share coping mechanisms and support each other so that a participant can feel less alone. Furthermore, meeting with other survivors allows the victim to discuss the rape experience without feelings of being judged and shamed.

The nurse is caring for a rape victim who refuses the prescribed antibiotics. Which response by the nurse is correct?

"The medication will help treat possible STIs" Common STIs and their TXs: Syphilis, treated c penicillin Chlamydia, treated with a dose of azithromycin or a week of doxycycline Gonorrhea, treated with a combination of ceftriaxone and azithromycin Trichomoniasis, treated with metronidazole or tinidazole

The nurse is caring for a victim of rape who has been attending group therapy. Which pt statement indicates an outcome of the plan of care has been met?

"The rape was not my fault." The acknowledgment that the rape was not the fault of the patient demonstrates self-acceptance.

The nurse is reviewing the prescribed treatment for a male victim of rape. The patient asks, "Why is an anal swab required?" Which statement by the nurse is most appropriate?

"To collect DNA and to check for sexually transmitted infections." Labs for rape: Vaginal, oral, and anal swabs for DNA material. Scrapings from under the patient's fingernails for skin samples if the patient scratched the rapist. Combing of pubic hair for the rapist's DNA. Clothing worn by the victim.

The nurse is preparing to administer an inotropic drug to a patient who was critically injured in an accident. The patient's spouse asks why the medication is needed. Which response by the nurse is best?

"To help the body tissues get more oxygen." Inotropic drugs are used to increase myocardial contractility and improve tissue perfusion. Vasopressors can be used in conjunction with fluids to treat septic, neurogenic, or anaphylactic shock. Opioid analgesics are used to manage pain. IV fluids and oral fluid intake help replace fluids lost from bleeding.

The nurse administers a vasopressor to a patient who has a serious infection. The patient's pulse is 142 beats/min, and the bp is 84/32 mmHg. The patient's family asks about the purpose of the medication. Which response by the nurse is accurate?

"Vasopressors can be used to increase bp." Vasopressors are used in conjunction with fluid replacement to treat shock states by inducing vasoconstriction & increasing bp. Opioid analgesics are used to treat pain. Inotropic drugs are used to help the heart pump stronger, resulting in increased cardiac output & improved tissue perfusion.

A self-employed patient with a preexisting condition is applying for insurance and is concerned about being denied coverage. Which statement by the patient's insurance representative is correct?

"You may find it difficult to purchase health insurance through private insurers."

The nurse has just completed hospital orientation. Which statement by the nurse reflects correct understanding of the role of the OSHA)?

*Employers must reduce or eliminate workplace hazards *Employers must maintain conditions or adopt practices that are needed to protect workers on the job. *OSHA provides employer & employee training materials that address workplace safety & health hazards *OSHA requires my employer to provide me c PPE when it is needed to protect my health & safety. Employers must comply c standards for a wide variety of workplace hazards in industrial & healthcare​ settings; OSHA requires employers to maintain conditions or adopt practices that are needed to protect workers on the job.​ OSHA's strategies for promoting improved workplace safety & health include providing employer & employee c info & training materials that focus on workplace safety & health hazards.

A nurse is developing a plan of care for a client diagnosed with PTSD who was admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority nursing diagnosis for this​ client?

. Risk for​ Self-Directed Violence

The nurse is providing education about sexual abuse and rape to the parent of a young child. Which statement describes the reason the nurse will discuss the subject matter with the parent?

A large percentage of survivors report having been raped prior to 18 YO. Being young could be considered a risk factor for rape, but only because a large percentage of survivors report having been raped before they were 18 years old.

nurse is caring for several patients on the medical unit in the local hospital. Which patient would most likely benefit from the use of a complementary health approach?

A patient who had the right leg amputated after an accident. Pts with long-term disability requiring therapy and rehab are most likely to benefit from complementary or alternate health approaches in conjunction with traditional medical care. The pt with the amputated limb is most likely to benefit from this type of care

A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime. Which has the client identified based on this​ data?

A vulnerability factor. Vulnerability factors increase​ one's risk of being a victim of violence. The pt c a walking disability avoids the possibility of a crime by not going out alone at night. A protective factor decreases the risk of perpetration & victimization. Risk factors increase potential that one will perpetrate violence on others. Precipitating factors are those that give rise to a specific incident of violence.

The nurse is caring for multiple patients in a busy emergency department. Which patient should the nurse anticipate will need immediate surgery?

A young man with a gunshot wound to the torso.

The nurse in the emergency department receives an order to set up for diagnostic peritoneal lavage for an incoming patient. Which type of injury should the nurse anticipate the patient may have?

Abdominal bleeding. Peritoneal lavage is used to look for blood in the abdomen or peritoneal cavity. A pt with an abdominal injury and suspected bleeding would be most likely to have this test. Fractures are evaluated by x-ray. CT or magnetic resonance imaging (MRI) scans evaluate a pt for head injury.

The nurse is reviewing a plan of care for a patient diagnosed with PTSD. Which intervention should the nurse question?

Administer fluoxetine as ordered.. Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI) not approved by the U.S. Food and Drug Administration (FDA) for use in treating PTSD. The only two SSRIs approved by the FDA for the treatment of PTSD are sertraline (Zoloft) and paroxetine (Paxil).

A client is brought into the ED after being in a MVC. The client has suffered traumatic injury that may involve multiple body systems. Which assessment is the highest priority for this​ client?

Airway maintenance c cervical spine protection.

The nurse is using open-ended questions during an assessment of a patient with PTSD. Which is a benefit of this therapeutic technique?

Allows the patient to express thoughts and feelings comfortably. Through the inclusion of open-ended questions, the nurse affords the patient the opportunity to express thoughts and feelings to the degree with which the patient is comfortable while demonstrating respect for the patient's personal boundaries

Which agency is responsible for administering a law once it has passed?

An executive branch agency of the federal or state government. Once a law has been passed, the executive branch of the federal or state government is responsible for administering it. The judicial branch has the responsibility for enforcing a law. No one role is responsible for administering a law.

The nurse is working with a coalition of local organizations on violence prevention after a series of assaults and murders by members of youth gangs in the community. Which intervention should the nurse suggest be offered to the community?

Anger management. The nurse would offer a multidisciplinary approach, problem-solving education, & anger management to the community. Violent adolescents & young adults exhibit range of problems: Truancy & dropping out of school. Substance abuse. Compulsive lying. Reckless driving. Contraction of STDS. ** Recklessness & instability of adolescence is partially responsible for high levels of youth violence, but there are close links between youth violence & experiences in childhood. Witnessing violence in the family is another relevant factor.

The nurse is working with a rape survivor. Which eating disorder should the nurse monitor in the patient?

Anorexia. Rape survivors are at a high risk for developing an eating disorder, including anorexia, bulimia, or a crossover between the two. One of the main components of both anorexia & bulimia is control over what the individual is consuming and over the nutrients that stay in the body or are forcefully discarded

The ED nurse is obtaining a history from a patient following a date rape. Which prescription should the nurse anticipate for the patient?

Antibiotic. Commonly used antibiotics for prophylactic treatment of STIs for rape victim: Penicillin Azithromycin Doxycycline Ceftriaxone Metronidazole Tinidazole

The nurse is caring for a client who is the victim of domestic violence and is visited by the spouse in the hospital. The client has indicated that she plans to return to her spouse when she leaves the hospital. Which action by the nurse supports the client when the spouse is​ present?

Ask the client if there is anything that is needed at this time..

The nurse just received notification that a patient with a major trauma will be arriving at the emergency department in a few minutes. Which should the nurse prepare to do first?

Assess airway and breathing.. The priority when caring for any trauma patient is to immediately assess the ABCDEs (airway, breathing, circulation, disability and neurologic assessment, exposure and environmental control) and be prepared to place an airway or assist with breathing or circulation.

The nurse is caring for an older patient who reports being raped 6 months ago. Which nursing action is most appropriate for this patient?

Assess for eating disturbances. Long-term emotional responses to rape include: Anger Flashbacks Avoidance of previously enjoyed activities Avoidance of the setting where the rape occurred Insomnia Eating disturbances Sexual dysfunction

middle-aged woman who has been physically and financially abused by her son tells the nurse, "I am not pressing charges against my son because I am afraid that he will put me out on the street, and I will have no place to go." Which should be the priority nursing intervention for this patient?

Assess the patient's safety and help her develop a safety plan.

The nurse is caring for a rape victim who is scheduled for a session with a therapist. Which statement describes the specific benefit of a therapist during the initial stages of therapy?

Assists the patient in processing the trauma. Initially after the trauma, a therapist can help an individual process the trauma. The therapist can later assist the patient with the identification of coping mechanisms and improving self-esteem through group therapy, CBT, or individually working with the patient.

The nurse is teaching a patient with PTSD. Which is the correct instruction about when to incorporate the act of abdominal breathing?

At the first sign of anxiety.

The nurse is counseling a man who confesses to pushing his wife when he gets really mad. The patient asks the nurse what he can do to help control his temper. Which is the best advice by the nurse?

Avoid using drugs or alcohol.. Although alcohol and drug use don't cause violent behavior, their use can increase the risk of it occurring. It can also contribute to aggressive behavior, which can lead to abuse

he nurse is caring for several clients in the ED. Which individual is a victim of community​ violence?

A​ 20-year-old man who was shot during a gang dispute

The nurse is caring for a patient recently diagnosed with PTSD. His mental health provider is providing eye-movement desensitization and reprocessing (EMDR) & CBT. The pt has demonstrated good progress but presents at the clinic with reports of an inability to sleep due to nightmares and difficulty meeting his daily obligations. Which intervention best addresses this symptom of PTSD?

Begin pharmacotherapy.. This pt is already actively engaged in nonpharmacologic therapies. At this time, the pt may benefit from adding a med to the tx regimen. The antihypertensive prazosin inhibits the brain's response to norepi, and it may be prescribed for treatment & prevention of nightmares

The nurse is caring for a rape victim in the ED. Which term describes a psychologic element of rape?

Berating. The psychologic elements of rape include berating the victim. Anxiety, perceived danger, and distress are consequences of the psychologic element of rape. Elements of rape include: Physical violence (being threatened or tortured). Psychologic abuse (being told the rape was the victim's fault).

An assault victim has inflammation, swelling, pain, and bruising. Which should the nurse suspect as the most likely cause of the symptoms?

Bone fractures due to a physical attack. Inflammation, swelling, pain, & bruising are clinical manifestations of bone fractures resulting from a physical attack. Clinical manifestations of a gsw are shock, profuse bleeding, pain, & inflammation. Clinical manifestations of a stabbing are shock, bleeding, pain, & inflammation. Clinical manifestations of internal bleeding as a result of blunt-force trauma include shock, dizziness, confusion, abdominal pain, and chest pain.

The nurse at a prenatal clinic listens as a 17 YO pregnant pt talks about her boyfriend. The patient states, "He beat up his ex-wife a lot of times, but so far, he hasn't done more than yell at me." Which feature of the situation is evidence that the young woman is at high risk of violence?

Boyfriend's previous behavior. The boyfriend's previous behavior makes this a high-risk situation for violence. The 3 phases in the cycle of violence are as follows: Tension builds between individuals in a relationship as communication fails or expectations are not met. An abusive or threatening incident occurs. The aggressor shows love and affection and promises to change, causing the victim to feel responsible and consider reconciliation (honeymoon phase)

The nurse is caring for a victim of rape in the ED. Which action should not be included in the nursing plan of care?

Calling the police. The police are not called unless requested by the victim. Providing safety for the patient prior to the assessment, assessing the wounds, and offering counseling services are part of the nursing care of the patient.

A home health nurse is caring for a patient who requires an appt. with a specialty provider. The PTs health insurance is an employer-provided health maintenance organization (HMO). Based on the PT's insurance, which is the first step for the nurse to take to ensure that this patient is seen by the specialist?

Calling the primary HCP for a referral to the specialist.

The nurse is caring for a patient who is suspected of having whiplash as a result of a MVC. The nurse understands that the sudden impact of an MVC can cause damage to which body part?

Cervical spine. Injuries are very common as a result of an MVC and can range from minor to severe. Whiplash results when the patient's head and neck are jostled or contorted during impact, causing damage to the cervical spine. Head trauma, dashboard knee, and punctured lungs result from blunt-force trauma.

The nurse is assessing a child diagnosed with PTSD. Which finding should be the priority?

Changes in sleeping patterns. ID of PTSD in children is improved when they are questioned directly about their experiences. Assessment of younger children involves questioning the child and/or parents about significant changes in behavior & sleeping patterns. Lack of social support, history of TIB, & history of suicide attempts are vital info for other patient populations but are not critical for the pediatric population.

The nurse is teaching the parents of an 8-year-old child who sustained a head injury from a motor vehicle crash. Which info should the nurse include?

Children with a head injury are more likely to experience seizures.. Children are more likely to experience seizures after head trauma. These seizures usually resolve, but they require diagnostic testing c a CT scan. Support for the infant/child/adolescent: Monitoring the child around the clock for additional manifestations. Insisting on safety seats in any mode of transportation. Reporting any suspected abuse. Putting locks on pools and hot tubs.

The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder. Which outcomes would indicate the interventions in the plan of care have been​ effective?

Cient verbalizes future plans with family and friends. The client has been sleeping throughout the night.

The nurse is caring for an older patient who is experiencing PTSD after being raped. Which collaborative intervention should the nurse include in the plan of care?

Cognitive-behavioral therapy. Long-term emotional responses to rape: Anger Flashbacks Avoidance of previously enjoyed activities Avoidance of the setting where the rape occurred Insomnia Eating disturbances Sexual dysfunction

The nurse is caring for a young girl who spent the first 5 yrs of her life locked in a windowless room by her parents without reliable access to healthy food or clean water. Which type of trauma did this patient experience?

Complex trauma. A complex trauma is an interpersonal trauma that usually begins in childhood and occurs from direct harm. In this case, the trauma stemmed from severe abuse & neglect. A simple assault is an attack against another person without the use of a weapon. Community violence results from conflicts between people who are not family members. Major trauma is a serious injury that can affect a single body system or multiple body systems.

After an​ assessment, the nurse suspects a client c multiple injuries is a victim of domestic violence. Which action should occur​ next?

Conducting a team assessment. If the nursing assessment reveals possible domestic​ violence, a primary focus will be treating the injuries.​ However, tx is often done by a​ team, which means a team assessment needs to be conducted before tx can take place. The police may need to be notified later.

The community health nurse is designing a presentation about societal factors that influence health policy. Which statement should the nurse include in the presentation?

Considerations include whether or not current policy benefits meets the population's needs..

A young woman presents to the emergency department and informs the nurse of being raped by her date this evening. Which test should the nurse anticipate the healthcare provider to order?

DNA swabs. DNA swabs are essential whenever someone is sexually assaulted because they can help to identify the attacker

For patients diagnosed with PTSD, which medical condition may accompany PTSD, as well as other anxiety disorders?

Depression. emotional numbness associated c PTSD can lead to: Depression. Alcohol abuse. Substance abuse. Impairment in establishing and maintaining social relationships.

The nurse is caring for a patient who has been raped. Which is the most important nursing consideration when providing care for the patient?

Developmental age. The most important nursing consideration when caring for a patient who has been raped is the developmental age of the patient. The approach to nursing care, interventions, and communication will be based on the patient's developmental age.

The nurse is caring for a patient who experienced a rape several months prior. Which collaborative team member may need to be included in the plan of care for the patient?

Dietitian. Rape survivors are at a high risk for developing an eating disorder, including anorexia, bulimia, or a crossover between the two. The patient may require a dietitian to assist with nutritional needs

A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing PTSD?

Difficulty sleeping, alcohol abse, aggressive behavior.

The nurse is caring for a patient with PTSD who is blocking emotions related to the traumatic event. Which clinical manifestation is the patient experiencing?

Dissociation. dissociation may occur, in which the individual blocks emotions r/T the traumatic event. *Flashbacks: losing touch c reality & cognitively returning to the traumatic event. *Depersonalization: Emotional numbing & loss of sense of reality, feelings, & sense of self in relation to others *Hyperarousal & hypervigilance: Near constant state of "high-alert" *Dissociation: blocking emotions r/t traumatic even *Dissociative amnesia: certain elements of the traumatic event blocked altogether

The nurse has just been hired at a home care agency and is asked to choose an insurance plan. The nurse selects a consumer-driven healthcare plan (CDHP). Which statement describes this plan?

Employer-sponsored coverage that combines a private insurance plan with a health savings account (HSA) or health reimbursement account (HRA).

The nurse is speaking with a colleague about the nurse's negative feelings when caring for a man who was suspected of physical abuse of his wife and children. Which advice should the colleague suggest to help the nurse?

Encourage the nurse to self-reflect in a journal to ID any existing biases. When caring for a perpetrator of abuse or violence, it is important for nurses to reflect on their feelings about caring for this individual because such pts are just as entitled to quality healthcare as other patients. Self-reflection can help the nurse to identify potential biases that might interfere with the nurse's ability to care for the patient.

The nurse caring for a patient who has experienced rape is focusing on therapeutic communication. Which communication technique should the nurse utilize?

Encourage the patient to ask questions.. The nurse will facilitate communication with the patient by encouraging the patient to ask questions. Providing reassurance addresses the concept of development.

A patient tells the nurse, "It has been 3 months, and still I have a hard time talking about the crash and the death of my friend who was driving." Which intervention should the nurse implement?

Encouraging the patient to express feelings about the traumatic event.

A teenager recovering from a gunshot wound tells the nurse about being angry with the assailant and afraid to go outside. Which intervention should the nurse implement?

Encouraging the patient to seek counseling for personal growth. The pt is doing well physiologically but not psychosocially. The patient is verbalizing emotions & concerns, which is positive. However, what the patient is expressing is fear and anger. These are the feelings that underlie assault and homicide. In the nurse's assessment of the patient's psychosocial well-being, it may be found that the patient has not made the necessary changes to promote and enhance personal safety, including seeking help when needed.

A 5 YO who has been physically abused is having difficulty putting her feelings into words. Which nursing intervention would best enable the child to express her feelings?

Engaging in play therapy. The toys and dolls in a play therapy room are useful props to help the child remember situations and reexperience the feelings; acting out the experiences with toys rather than putting them into words is sometimes easier for the child.

The school nurse becomes aware that one of the students in the school is being severely abused by the student's parents. Which nursing action is the priority?

Ensure the safety of the child. Child abuse can take three forms: Neglect Physical abuse Sexual abuse In 2013, neglect accounted for most cases of child abuse in the US. Most perpetrators were adults under 44, and women were more often the abuser.

The telephone hotline nurse is fielding a complex question about possible intimate partner abuse. From the description that the caller is giving, abuse seems likely. Which is the first priority of the advice nurse?

Ensuring safety from the partner's abuse.

Some patients with PTSD experience hyperarousal & vigilance. Which intervention should be the nursing priority for patients experiencing these symptoms?

Ensuring the safety of the patient. Nursing priorities for patients c PTSD exhibiting hyperarousal & vigilance are ensuring the safety of the pt & others while quickly lowering pt anxiety levels. Pts experiencing extreme anxiety also require pharm intervention, a quiet and calm environment, & reassurance about personal safety

A patient with PTSD reports having repetitive negative thoughts and emotions. Which action should the nurse suggest to alleviate negative thoughts and feelings?

Exercise.

the nurse is caring for a 30 YO 3 months after her assault. Her symptoms include sense of detachment, altered sense of reality, spontaneous memories of the assault, recurring distressing dreams, psychological distress & inability to return to her apartment. Which risk factor should lead the nurse to suspect that the patient is experiencing PTSD

Experiencing an extremely stressful event. Risk factors for PTSD: Severity of the event itself, including whether or not the individual was harmed or watched others be harmed or killed; Little or no social or psychologic support following the trauma; Additional stressors immediately following the event, such as loss of a spouse or family member or loss of employment; Presence of preexisting mental illness

A client is admitted with injuries sustained from a domestic dispute. When planning​ care, the nurse will include which​ short-term interventions?

Explore option for help; determine immediacy of danger; convey safety. he nurse is caring for several clients in the emergency department. Which individual is a victim of community​ violence?

Which form of therapy might be used to help an individual with PTSD visit the location where a traumatic event​ occurred?

Exposure therapy

A patient with PTSD wishes to include nonpharm therapy as part of the treatment regimen. Which form of nonpharm herapy allows the patient to develop effective coping skills in a safe, controlled environment?

Exposure therapy. Exposure therapy allows the patient to develop effective coping skills in a safe, controlled environment. Exposure therapy assists by gradually exposing the patient to elements of the traumatic event, which enables the patient to face fears. The use of virtual reality also assists the patient in revisiting the site where the traumatic event occurred without having to go back to the real site.

The most effective nonpharm therapy for PTSD is cognitive-behavioral therapy (CBT). Which form of nonpharm psychotherapy contains elements of CBT and body-centered therapy?

Eye-movement desensitization and reprocessing (EMDR). EMDR is a form of psychotherapy that contains elements of several types of therapy, including CBT and body-centered therapy. Nonpharm therapy options: EMDR CBT Body-centered therapy Exposure therapy Acupuncture

The nurse is caring for the parents of a young child who was beaten up at school by another student. The healthcare provider orders the focused assessment by sonography in trauma (FAST) test. Which purpose should the nurse expect this test to fulfill?

Finding blood in body cavities.

The nurse is assessing a male patient who left his abusive spouse 6 months ago. The patient states that sometimes he'll smell whiskey, which was his partner's favorite drink, and it's like he's right back in the relationship with the partner. In which category should the nurse decide to document this patient's experience?

Flashbacks to the abusive situation.

The nurse is reviewing the chart for a patient who is exhibiting signs of the inability to recover from a rape. Which assessment finding should the nurse anticipate?

Flashbacks. The assessment finding the nurse anticipates for the patient exhibiting signs of inability to recover from a rape is flashbacks. Flashbacks are a clinical manifestation of PTSD. Periods of shame, hostility, and an increased startle reaction occur during the acute phase of rape-trauma syndrome.

PTSD & SSRIs

Fluoxetine (Prozac) is an SSRI NOT approved by the U.S. FDA for use in treating PTSD. The only two SSRIs approved by the FDA for the treatment of PTSD are sertraline (Zoloft) and paroxetine (Paxil).

A patient presents to the ED after a major motor vehicle crash. While undressing the patient, the nurse notes significant bruising on the abdomen. Which test should the nurse anticipate the healthcare provider may order?

Focused assessment by sonography in trauma (FAST). FAST test evaluates the presence of blood in the body cavities, specifically in the abd, peritoneum, pleura, & pericardium. FAST exam can help to ID bleeding in the following body cavities: Peritoneum, Abdomen, Pleura, Pericardium.

The nurse leader is planning an in-service about healthcare policies that have direct effects on the nation's health. Which content is appropriate for inclusion in the presentation?

Food and Drug Administration (FDA) is governed by the U.S. Department of Health and Human Services (DHHS). DHHS governs more than 300 divisions & programs, including the following: National Institutes of Health (NIH), which provides health research & other health-related info; Centers for Medicare & Medicaid Services (CMS), which addresses healthcare financing issues; & the Administration for Children & Families & the Administration on Aging, which oversee services for individuals throughout the lifespan. Divisions governed by the DHHS also include FDA & CDC

The nurse is providing information to a rape victim about the importance of following up with prescribed diagnostic testing. Which prescribed diagnostic test performed initially will be repeated at 3, 6, and 12 months?

HIV.

The nurse suspects a client is experiencing PTSD when which are noted during the assessment​ process?

Has a history of anxiety disorder Observed family member being raped and murdered Recently terminated from employment

Which nongovernmental organizations have an influence on health policy?

Health professions associations.

RB is discharging a client who was admitted for surgery for a compound ulnar tx that occurred during a conflict c the​ client's spouse. The client​ states, "I hope this cast comes off before summer. Last night my husband promised me he is going to take me to Hawaii this summer. After he broke my​ jaw, we went to​ Rome." Based on this​ data, which phase of violence is the client​ experiencing?

Honeymoon phase.

The nurse is planning to teach a group of adolescents about driving safety. The nurse should focus on which primary cause of MVCs

Human error. Human error is the primary cause of MVCs. Other risk factors: forces of nature (animals entering the roadway), weather (snow, ice, rain, fog), age (16-19 & over 65), speeding (driving over the speed limit), distracted driving (texting, making phone calls, putting on makeup, eating, dealing with children), aggressive driving (road rage, arguments with passengers, tailgating), and health conditions (exacerbation of a chronic heart or respiratory disorder or other medical condition).

The nurse is providing care to a patient who sustained a fracture during a motor vehicle crash. Which pharmacologic treatment should the nurse anticipate for this patient?

Hydrocodone.

The nurse is preparing a presentation regarding multisystem traumas that result from MVCs. Which cause related to human error should the nurse include?

Impaired driving. Although some MVCs are influenced by forces of nature, like deer or other forms of wildlife running across the road or a sudden rainstorm, the primary cause of MVCs is human error. Some of the main risk factors for MVCs: age, speeding, distraction, aggressive driving, and impaired driving. Risk factors for trauma include the following: MVC. Poisoning. abuse Drowning. Falls. Natural disasters. Homicide. Suicide. Interpersonal violence. Community and systemic violence. Accidental/incidental trauma

The nurse is teaching a group of parents whose children have been diagnosed with PTSD. Which symptoms should the nurse include in the teaching about PTSD in adolescents?

Impulsive, aggressive behavior. Adolescents may engage in traumatic reenactment where the traumatic events are injected into their daily lives. Impulsive, aggressive behaviors are more typical in this age group. Children <6 may socially withdraw or become exceptionally needy or clingy. Older pts may experience somatic symptoms. Older children & adolescents have manifestations similar to those that the adult has; but, they may also demonstrate disruptive, disrespectful, or destructive behaviors. Furthermore, there is an increased risk of suicide, substance abuse, poor social support, poor concentration, academic problems, & poor physical health c adolescents diagnosed c PTSD.

The nurse is caring for a client who was diagnosed with PTSD 4 months ago. Which should the nurse include in the​ client's plan of​ care?

Info on the treatments available

Evaluating assessment data for an individual with PTSD can be challenging. Which condition can compound the manifestations of PTSD for some patients?

Insomnia. For some patients with PTSD, manifestations of the disorder can be compounded by substance abuse, depression, and insomnia.

A school-aged child confides in the nurse that another child steals his lunch money every day. The nurse understands that this is an example of which type of violence?

Instrumental aggression. Childhood bullying is an example of instrumental aggression, which occurs when there is aggression in the absence of emotional arousal, such as with bullying. Complex traumas occur repeatedly & are cumulative. They also occur from direct harm like abuse, neglect, and exploitation. Examples of neglect include poor hygiene and lack of medical care or dental care. Aggravated assault is physical assault with a weapon.

Which cause should the nurse associate with a higher incidence of PTSD?

Intentional infliction of violence.Intentional infliction of harm or violence, such as torture or rape, is associated with a higher incidence of PTSD. PTSD can also be triggered by natural disasters, motor vehicle crashes, and imprisonment, but these triggers are less prevalent than intentional infliction of harm or violence.

The nurse caring for a patient who experienced blunt-force trauma to the abdomen monitors for signs of blood in the stool. Which rationale should the nurse give as the reason for this action?

Internal hemorrhage. Actions for blunt-force trauma of the abdomen include: Checking the stool for blood. Checking vital signs. Palpating the abdomen.

The nurse in the ED is caring for a female patient who was brought in by a neighbor. The right side of the patient's face is swollen, bruised, and bleeding. The pt's husband arrives and does not let the wife speak; the husband answers all the questions for the patient. Which type of abuse should the nurse suspect?

Intimate partner violence.

The nurse is teaching a group of teachers about signs of sexual abuse to watch for in students. Which sign should the nurse include?

Isolation from peers. Behavioral symptoms of children who have been sexually abused include a lack of peer friendship or isolation from other peers. Unwilling to participate in physical activities. Wears long sleeves and several layers of clothing even in hot weather. Delinquency or running away. Inappropriate sexual behavior or mannerisms. Regressive behaviors

The nurse is teaching about an individual's risk factors for perpetration of sexual violence. Which factor included by a participate indicates the need for further teaching?

Late sexual initiation. Risk factors for an individual's perpetration of sexual violence: Delinquency. Empathic deficits. General aggressiveness and acceptance of violence. Early sexual initiation. Coercive sexual fantasies. Preference for impersonal sex and sexual risk taking. Exposure to sexually explicit media. Hostility toward women. Adherence to traditional gender-role norms Hyper-masculinity Suicidal behavior. Prior sexual victimization or perpetration

The nurse manager is reviewing an incident report prepared by a new nurse who claims that a more experienced peer is showing hostile and aggressive behavior. The nurse manager understands that this is an example of which type of workplace violence?

Lateral violence. Lateral, or horizontal, violence occurs between an individual and other members of the same group, which in this example is the group of nurses working on the unit. Vertical violence occurs between people who are on different levels of the hierarchy. Systemic violence is a deliberate attempt to cause social injustice or inequality. Unintentional violence, or trauma, is caused by unintentional actions, including accidents or continuous stressors.

A patient presents with muscle pain and spasm due to a whiplash injury. Which therapy should the nurse expect to be ordered?

Lidocaine injection. Lidocaine injections into affected muscle to relieve pain & muscle spasms would be ordered for pts experiencing whiplash injury. majority of injuries sustained will be painful to pts & will require pain management with oxycodone or morphine. Clinical therapies for a patient with whiplash: Rx pain relievers such as hydrocodone or oxycodone Muscle relaxants to relieve muscle spasms Lidocaine injections into affected muscle to relieve pain & muscle spasms Ice & heat therapy Physical therapy Immobilization collar to promote proper healing

The nurse is caring for a patient who experienced a deep laceration to the arm as the result of an assault. The patient is resting comfortably and is denying any pain but will need sutures to close the wound. Which pharm therapy should the nurse anticipate for this patient prior to suturing?

Local anesthetic.

The nurse is caring for a pregnant woman who has been raped by her spouse. Which statement best describes the nurse's understanding of marital rape?

Marital rape is not acknowledged in some cultures.. Marital rape is not acknowledged in many cultures around the world. Marital rapes often go unreported

The nurse orienting to the emergency department is caring for a patient who presents with a right clavicular fracture. Which nursing intervention by the orienting nurse requires immediate correction from the preceptor?

Mediating a discussion between the victim and the abuser. Nursing interventions for intimate partner violence include initiating a thorough physical & emotional assessment; offering resources and assistance; and documenting the description and location of any bruising, burns, scars, and other physical injuries or abnormalities. Nursing interventions for intimate partner violence do not include mediating a discussion

The nurse is discussing Medicaid health coverage with a client. Which info should be​ included?

Medicaid is available to eligible​ individuals, families, older adult​ clients, & individuals c disabilities. Medicaid is a​ state-administered program that is available to certain​ lower-income individuals &​ families, older adult​ clients, & individuals c disabilities who meet eligibility requirements set by federal and state law. Federal laws require Medicaid to cover certain​ services, including hcp services, inpatient & outpatient hospital​ care, home health​ services, & transportation to medical care. Supplemental Security Income​ (SSI) provides cash for basic needs such as​ food, housing, and clothing.

Medicare

Medicare is a federally funded health insurance program that is available to people age 65 or​ older, younger people with​ disabilities, and people with​ end-stage renal disease. Certain​ services, including routine eye​ care, are not covered by Medicare. There are four types of Medicare​ coverage: Part A​ (hospital insurance), Part B​ (medical insurance), Part C​ (Medicare Advantage Plans like an HMO or​ PPO), and Part D​ (Medicare prescription drug​ coverage). **Routine eye care is not covered by Medicare.

The nurse is working with an older adult client to understand Medicare. Which plan is designed to supplement Medicare​ coverage?

Medigap policy. A Medigap policy​ (that is, Medicare supplemental​ insurance) is private health insurance designed to supplement Medicare coverage. Medicaid is coverage for lower income individuals and families. Medicare Part D is prescription coverage within Medicare

Which individual has the highest risk of developing​ PTSD?

Military veteran

The nurse suggests that a patient with PTSD should include exercise in the treatment regimen. Which aspect of PTSD can be reduced effectively through exercise?

Negative feelings. Nurses should help patients with PTSD to ID safe physical outlets for negative feelings, like exercise. The nurse may be responsible for teaching PTSD pts: How to monitor their physiologic level of arousal; use of abdominal breathing at the first sign of anxiety; need to express fears that interfere with their lives; need to search for, confront, and relieve the source of the original anxiety; use of positive imagery; use of calming techniques such as muscle relaxation; use of positive affirmations like "I am calm and happy" or "I am very relaxed"

A new nurse orienting to the emergency department admits a patient who was raped. Which action by the new nurse requires immediate follow-up by the preceptor?

Obtaining a history of the incident in the triage area. Interviewing the pt in the triage area does not provide the pt c privacy. Appropriate nursing interventions for this pt include placing the patient in a private room, providing tx for potential sti & administering emergency contraceptive meds with the permission of the patient.

A patient recently experienced a traumatic event. Which intervention, if started immediately after the exposure to trauma, prevents the normal stress reactions from developing into acute stress disorder or long-term PTSD?

Obtaining help & support. Obtaining help & support ASAP after exposure is integral in preventing normal stress reactions from developing into acute stress disorder or longer-term PTSD. most effective way to prevent PTSD is for the individual to use a support system after exposure to a traumatic event. This may mean reaching out to family & friends or seeking professional help, or obtaining support will aid the individual in using positive, effective coping skills & prevent the individual from succumbing to ineffective coping skills such as self-medicating with substances

Which substance should the nurse recognize as accounting for most drug-related poisonings?

Opioid analgesics. Opioid analgesics account for 40% of all drug-related poisonings, with the highest death rate attributed to males between 46 and 56 years of age. Poisonings are the leading cause of injury death in the US

The pediatric nurse welcomes the parents of a child adopted from an international agency. The child was orphaned after a border war and still has nightmares. Which diagnosis should the pediatric nurse be prepared to explain to the family?

PTSD. Special considerations for PTSD: Exposure to overwhelming stressor can occur at any age. Childhood trauma, abuse, molestation can create enduring effects & clinical s/s that last into adulthood. Additional factors that contribute to PTSD are individual hx of a psychiatric disorder or lack of emotional support or resources during trauma. Refugee trauma is a form of PTSD that is specific to the traumatic events experienced by individuals during war or persecution that may have lifelong effects. Child refugees may exhibit s/s like nightmares, anxiety, psychosomatic symptoms, hopelessness, disrupted sleep patterns. Children c PTSD may also behave recklessly or aggressively, or they may withdraw from interacting c others. Because of their undeveloped ability to express thoughts or ID emotions, expressions of PTSD in very young children often occur through changes in mood.

The nurse is caring for a patient with physical injuries resulting from rape. Which nursing diagnosis is the most appropriate for the patient?

Pain, Acute

A patient presents to the ED with a 10-cm laceration on the leg after sustaining a fall. The patient complains of pain at a 6 out of 10. Which intervention should the nurse do first?

Perform an abbreviated nursing assessment and health interview.. When caring for a pt with a traumatic injury, the initial focus by the nurse must be stabilizing the patient physiologically. It is preferable to perform a brief health interview and assessment before administering an opioid analgesic so that the pt is awake and alert when providing crucial information.

A patient has been in a coma for about 6 weeks following a MVC. Which collaborative intervention should the nurse expect to be most beneficial for the patient?

Physical therapy. PT and rehab are often required for severe injuries, including broken bones (especially compound fractures), spinal injuries, and some traumatic brain injuries. If the pt falls into a coma or is put into a drug-induced coma, PT and rehab will be needed if muscle tone decreases significantly while the patient is unconscious.

The nurse is caring for a pregnant woman experiencing severe blood loss after a MVC. Which factor should the nurse know may be fatal for the fetus?

Placenta being deprived of oxygen. An increase in blood volume occurs in the pregnant woman. In cases of severe blood loss, the fetus may be in distress and the placenta deprived of O2 before symptoms (tachycardia, hypotension, & other signs of hypovolemia) occur in the mother. The mother's condition and vitals may initially appear stable with hypovolemia. It is also important to keep uterine compression of the vena cava from occurring.

The nurse is planning to initiate a new type of support group for young children who have been the victims of abuse and neglect. Which type of activity should the nurse plan?

Play therapy. Play therapy is most appropriate for young children who are recovering from a trauma like abuse. It can also help them process what happened to them

The nurse is reviewing the risk factors for sexual violence related to personal relationships. Which risk should the nurse associate with perpetrators' personal relationships?

Poor parent-child relationship. risk factor for sexual violence the nurse associates c perpetrators' personal relationships is poor parent-child relationships. This occurs particularly with poor father-child relationships. Poverty is a community factor. Hostility toward women is an individual risk factor. Societal norms that support sexual violence are a societal risk factor.

A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman. Which nursing diagnosis is the priority for this​ client?

Post-Trauma Syndrome

The nurse is providing care to a child diagnosed with PTSD who is experiencing frequent nightmares. Which med should the nurse anticipate being prescribed for this patient?

Prazosin. Although sertraline, paroxetine, & risperidone are appropriate for a pt diagnosed c PTSD, the only med that has shown effectiveness in reducing nightmares associated c PTSD is prazosin, an antihypertensive. The only two SSRIs approved by the U.S. FDA for the tx of PTSD are: Sertraline (Zoloft) Paroxetine (Paxil)

A client is admitted with a diagnosis of PTSD. During a review of the​ client's HX, the nurse is made aware that the client suffers from depression and suicidal thoughts. While interviewing the​ client, the client tells the nurse he is feeling extremely irritable and that the main reason he is there is because he has been having frequent nightmares. Based on the assessment​ findings, which medication prescription does the nurse anticipate for this​ client?

Prazosin​ (Minipress)

The public health nurse is visiting the home of an older woman. Looking out the window, the nurse sees graffiti, empty beer cans, and discarded trash items. Which term describes the fact that this woman is more likely to be a victim of violence based on her environment?

Predisposing factor. Graffiti, empty beer cans, and discarded trash items can be signs of a low-income environment. That setting is a predisposing factor for violence

The nurse assesses a patient with a gunshot wound and notes that the patient's bp has significantly dropped and that symptoms of shock are occurring. Which nursing intervention is the priority?

Preparing IV fluid administration. The list of actions as per their priority is: Initiating intubation Administering meds Updating family members on the patient's condition

The nurse suspects that a patient is being abused by a partner, but the patient denies that anything wrong is happening at home. Which is the best action by the nurse?

Provide a list of referrals in case the patient decides to leave.. Ultimately, it is up to the patient whether or not to leave the partner. The nurse can provide information about community resources that can help the patient decide whether to leave, but the nurse cannot report the abuse to the authorities or social services (unless children are involved).

Which nursing interventions would be appropriate for a client demonstrating extreme anxiety related to PTSD

Provide a​ calm, quiet environment. Reassure the client that the environment is safe.

The community nurse has noticed an increase in fatalities of young adults from motor vehicle crashes in the local community. Which intervention should be implemented to best help to address this concern?

Providing teaching about seat belts & avoiding cell phone use in the car. Interventions that can help prevent mvcs: routine use of seat belts & not using cell phones while driving. Teaching teens about these measures can help to reduce the incidence of and fatalities from mvc. There are 6 key principles that the nurse should keep in mind while addressing needs of trauma victims: Safety Trustworthiness & transparency Peer support Collaboration and mutuality Empowerment, voice, and choice Cultural, historical, and gender issues

The nurse is caring for a 3 YO who has dime-size burns on the legs and bruises in various stages of healing on the abd and back. Which is an appropriate nonpharmacologic treatment for this child?

Refer the child for play therapy.. Appropriate nonpharmacologic interventions for abused or neglected children include play and cognitive, behavioral, and group therapy, depending on the age of the child

A woman wishes to take the children and leave her abusive husband. The patient has no family nearby and asks the nurse for help in finding somewhere to go. Which is the best referral by the nurse?

Referral to a domestic violence shelter that cares for women and children.

The nurse is providing care to a child who has suffered abuse. Which nursing actions are​ appropriate? Select all that apply.

Remind the child that he did nothing wrong & follow protocols for mandatory reporting.

An older adult patient is receiving home care services. The patient lives with a family member. The nurse suspects that the patient is being neglected after observing that the patient's hair and clothes are dirty and that the patient smells of urine. Which intervention would be a priority for this patient?

Report the neglect to the appropriate agency. Reporting the abuse to the appropriate agency, according to the requirements of state law, is a nonpharmacologic treatment of older adult abuse and takes priority in this case.

The nurse should recognize that which action is an example of continuous analysis and evaluation of results related to health policy?

Reviewing evidence indicating whether or not the policy effectively benefits the people it was intended to serve. 4 major stages in policymaking are agenda setting, government response, implementation, & evaluation.

The nurse is preparing a presentation about Supplemental Security Income (SSI). Which statement regarding how SSI differs from Medicaid should the nurse include?

SSI is a federal & state program for aged, blind, & disabled persons to help pay basic needs like food, clothing & housing. Supplemental Social Security Income (SSI) is a federal & state public assistance program designed to help the aged, blind & disabled people c basic needs such as food, clothing & housing. Medicaid is state funding to pay for medical expenses available to certain low-income individuals & families, older adult patients & people c disabilities. Welfare helps low-income people c public assistance.

A patient involved in a MVC has chest pain, shortness of breath, and bluish lips and nail beds and was wearing a seat belt in the MVC. Which injury should the nurse suspect?

Secondary punctured lung from a broken rib. Bluish coloring around the nails and lips, which means that there's a lack of O2 in the blood, as well as further complains of pain while inhaling and sob suggest an injury to the lungs and a possible puncture. Common injuries from a seat belts: Fractured ribs. Fractured collarbone. Internal injuries. Organ damage Potential for a punctured lung secondary to broken ribs

A nurse is transferring from a county to a city health department. Which is a responsibility of a city health department?

Sexual health. City health depts may provide clinical, environmental, health promotion, & population-based services such as free clinics, sexual health, HIV/AIDS testing & TB & dental clinics. County health depts are responsible for sanitation, retail food establishments, & waste disposal.

The nurse specializes in caring for victims of domestic violence and abuse and believes in the tenets of social learning theory. Which statement reflects this theory?

Social learning theory suggests that violence r/t abuse and neglect is a learned behavior. Violent individuals are conditioned to respond aggressively & violently. Neurobiological theory: tendency to abuse, neglect, & become violent toward others is a result of genetic considerations * distortion in neurotransmitters. Interpersonal theory: cause of violence lies in the personality of the individual who commits abuse; the perpetrator uses violence as a display of anger. Gender-bias theory: proposes that some families, cultures, & communities value subordination of women through power & privilege.

The nurse is caring for an older patient who is a veteran with PTSD. Which manifestation is reported more often by older veteran patients compared with younger veterans?

Somatic symptoms. Older veteran patients report more somatic complaints; fewer typical PTSD general symptoms; & less depression, hostility, & guilt than younger veterans. A complete mental status exam, including cognitive screening, is recommended when assessing older pts. Assessment of the hx of trauma & symptomatology should be performed routinely because these pts may minimize the significance of this hx or not report it at all because it likely occurred a long time ago.

A patient wishes to incorporate complementary integrative health (CIH) approaches in the treatment regimen for PTSD. Which type of CIH approach enables the patient to have an effective plan to address the negative obstacles that may be encountered?

Stress inoculation. Stress inoculation is a form of psychotherapy in which the therapist teaches the pt on the stress that may be endured, including the negative outcomes. This enables the pt to have an effective plan to address the negative obstacles that may be encountered.

The school nurse is leading a discussion on violence with a group of adolescents. Which factors could the school nurse indicate as protective factors that may decrease the risk of​ violence?

Success in school; involvement in the community; participation in family activities.

The nurse is caring for a patient experiencing the acute phase of rape-trauma syndrome (RTS) who is exhibiting a compound reaction. Which clinical manifestation should the nurse recognize as a reactivated condition?

Suicidal behavior. The nurse caring for the pt who is exhibiting a compound reaction in the acute phase of rape-trauma syndrome anticipates the reappearance of symptoms from previous conditions, such as suicidal behavior. Other reactivated symptoms could include psychotic behavior, depression, & substance abuse. During a compound reaction, reactivated symptoms of a previous condition occur in addition to the symptoms characteristic of the acute phase of RTS. Somatic reactions, guilt, & inappropriate laughter are clinical manifestations of the acute phase of rape.

The nurse is giving a presentation to middle school children about cyberbullying and the potential dangers associated with online abuse. Which manifestation should the nurse include as a potential complication?

Suicide. Cyberbullying has been known to cause anxiety, depression, and even suicide

The nurse is using a PTSD measuring tool during an assessment of a 70-year-old veteran. Older patients are at an increased risk of which occurrence compared with patients of other age groups?

Suicide. Older pts may report somatic symptoms as opposed to emotional symptoms & are at an increased risk of suicide. *Children c PTSD often express PTSD as: Changes in mood, Nocturnal enuresis,Forgetting how to talk or not talking at all, Acting out traumatic event during activities c other children; Being exceptionally needy or clingy. *Adolescents c PTSD may demonstrate: Disruptive, disrespectful, or destructive behavior, Traumatic reenactment where the traumatic events are injected into their daily lives, Impulsive & aggressive behaviors, Increased risk of suicide, substance abuse, poor social support, poor concentration, academic problems, & poor physical health

Common STIs and their TXs:

Syphilis, treated c penicillin Chlamydia, treated with a dose of azithromycin or a week of doxycycline Gonorrhea, treated with a combination of ceftriaxone and azithromycin Trichomoniasis, treated with metronidazole or tinidazole

The nurse is caring for a patient on the behavioral health unit who was in a MVC; the patient's husband did not survive the MVC. The patient is being treated for PTSD. Which independent nursing intervention should the nurse perform?

Teaching relaxation techniques. The nurse can help the patient with relaxation techniques, such as massage or guided imagery. Therapy, EMDR, and CBT must be performed by a licensed therapist or counselor.

Which agency accredits all types of nursing education programs?

The Accreditation Commission for Education in Nursing (ACEN).

Which statement describes the mission of the International Council of Nurses (ICN)?

The ICN represents nursing worldwide, advancing the profession and influencing health policy. International Council of Nurses (ICN), represents more than 16 million nurses worldwide, is the world's oldest organization for health professionals. It is a federation of more than 130 national nurses' associations c the mission to "represent nursing worldwide, advancing the profession and influencing health policy".

Which independent organization significantly influences national quality and safety standards in healthcare institutions?

The Joint Commission. Joint Com. is an independent, nongovernmental organization that significantly influences national quality and safety standards and the advancement of healthcare policy. CDC maintains information regarding mortality & morbidity rates, and also leads infection prevention in the US

Which is the only international health agency with legal authority?

The World Health Organization (WHO). The premier international health organization is the WHO, which is an intergovernmental agency related to the UN and the only international health organization with legal authority.

The nurse is assessing a​ 4 YO. Which assessment finding indicates to the nurse that the child might have suffered a traumatic​ event?

The child refuses to talk or answer questions when previously the child chatted constantly.

The nurse is assessing a 9 YO whose teacher suspects that the child is a victim of abuse. The physical assessment reveals no unexplained or untreated injuries & they do not appear to be malnourished or dehydrated. Which clinical manifestation should indicate to the nurse that this child might be a victim of abuse?

The child still wets the bed on some nights. Bedwetting in a 9-year-old is not a normal behavior and can indicate that abuse is present in the home

During the​ assessment, the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang. Which should the nurse assume regarding the​ client's behavior?

The client was reacting to the loud noise as a form of a flashback.

A nurse is developing a plan of care for a client diagnosed with PTSD. The client was recently admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority goal to include in the​ client's plan of​ care?

The client will remain free from injury or harm.

The nurse is evaluating the plan of care for a patient who experienced a pneumothorax during a mvc. Which observation by the nurse indicates that the patient is progressing toward independent mobility?

The patient coughs, turns, and deep breathes every 2 hours. Changing positions, coughing, deep breathing, and incentive spirometry reduce the risk of integumentary and respiratory complications and should be done at least every 2 hours. ROM exercises should be performed at least once every 8 hours.

A community nurse is caring for a young man who reports having an abusive spouse. The nurse is performing teaching to promote safety for this patient. Which outcome would indicate effective teaching?

The patient creates a safety plan..

The nurse is assessing the plan of care initiated for a patient who is a victim of rape. Which finding indicates that the plan of care should be revised?

The patient has refused to report the rape or accept help. The plan of care will be revised if the patient refuses to report the rape or accept help. The refusal of help indicates that the pt is still in the shock phase. Physical assessment components: DNA swabbing. Collection of scrapings from under the fingernails. Combing of the pubic hair to test DNA. Assessment for physical trauma.

The nurse is prioritizing care for patients who have been assaulted during a mass shooting at a local mall. Which patient requires priority care?

The patient with a gsw to the throat. The nurse prioritizes care based on the initial assessment of the patients who present for care. A patient with a bullet wound to the throat would require priority intervention because this patient is at risk for airway issues and circulatory issues

A young client is brought into the ED by a friend who says the client was​ "beat up" at school. The client has bruising & lacerations to the face and torso. The client is reluctant to provide the names of parents or a home address. What can the nurse safely assume about this​ client?

The pt is a victim of interpersonal violence.

What type of communication should the nurse employ when caring for a client who has suffered​ trauma?

Therapeutic communication

For which reason does the American Nurses Association (ANA) write issue briefs?

To express the association's opinion on how federal or state laws or proposed federal rules affect nurses & PTs. ANA writes briefs to express association's opinion on how federal or state laws or proposed federal rules affect nurses & pts. Additionally, they write position statements on specific issues related to bloodborne pathogens, consumer advocacy, drug & alcohol abuse, environmental health & ethics & human rights.

Which is a reason for a private agency to develop health policy?

To represent the interests of healthcare organizations.

Which injury should the nurse expect may require surgery to remove hematomas or repair the skull?

Traumatic brain injury. TBI may require surgery to remove hematomas, repair skull fx, or remove skull fragments from the brain and cutting out a section of the skull to allow for swelling of the brain, which diminishes pressure on the brain. A mild head injury and whiplash do not require surgery. A spinal cord injury may require surgery but not to remove hematomas or repair the skull. S/s of TBI: LOC, headache, n/v, dilation of one or both pupils, confusion, seizures, coma, death

The nurse reports to the scene of a natural disaster to assist first responders in caring for the victims. Which is the nurse's priority role?

Triaging the patients according to the severity of their injuries. When caring for multiple patients after a trauma, the nurse should first prioritize care by triaging their injuries according to the ABCDEs

nurse is preparing a presentation for community members who volunteer during natural disasters. The nurse should describe natural disasters as which type of trauma?

Unintentional. Unintentional trauma is that which is caused by an unintentional action. A natural disaster is an example of this type of trauma. Community violence arises from personal conflicts between people who are not family members. Systemic violence is a deliberate attempt to cause social injustice or inequality. Interpersonal violence occurs between people

A patient with PTSD wishes to add acupuncture to the tx regimen. Which info on acupuncture should the nurse include while teaching the patient?

Use acupuncture as an adjunctive therapy.. The U.S. Dept of Veterans Affairs & DOD ID the following as the front-line standard approach to PTSD: Psychopharmacology Stress inoculation Exposure Cognitive-behavioral therapy (CBT) Complementary integrative health (CIH) approaches, such as yoga & meditation, can also be taught

The nurse is caring for a patient who is experiencing delusions. Which factor may indicate that the nurse is not in a safe situation?

Use of violent language by the pt. Use of threatening or violent language can be a huge clue that the pt may be violent and that the nurse is in an unsafe situation. Warning signs of violent behavior include: Use of threatening or violent language Uncontrolled anger Aggression

A patient experienced a penetrating wound to the abdomen that required emergency surgery to remove the object and create a temporary colostomy. Which nursing intervention is the priority?

Using strict standard precautions and aseptic technique

nurse is conducting an assessment interview of a pt with unexplained rib fractures. To check whether the patient is a possible victim of domestic abuse, the nurse asks, "Has your partner ever hit you when feeling angry?" Which word in the nurse's phrasing of the question may help the patient answer the question honestly?

Using the word ever. The nurse makes the individual feel less intimidated in reporting domestic abuse by asking a question that can be answered with "sometimes" instead of only "yes" or "no. When caring for a pt who is experiencing trauma, the nurse must consider the patient's psychologic needs as well. This may include: Assessing the family for psychological, social, and spiritual needs. Providing referrals for counseling or financial support services. Assessing religious needs.

Rn is attending an orientation before starting work for the state health department. Over which dept or organization does the state health dept have jurisdiction?

Vital Statistics.

The nurse is teaching a class about hypovolemia in pregnant women with multisystem trauma. Which information should the nurse include?

Vitals may be stable. An increase in blood volume occurs in the pregnant woman. In cases of severe blood loss, the fetus may be in distress & the placenta deprived of O2 before symptoms (tachycardia, hypotension, & other signs of hypovolemia) occur in the mother. The mother's condition & vitals may initially appear stable with hypovolemia. It is also important to keep uterine compression of the vena cava from occurring. This can be completed by manually displacing the uterus to the left side, which relieves pressure on the inferior vena cava.

The nurse in the ED is being taught about the various diagnostic tests used for cases of abuse. When asked about which test will be performed for an abused patient who has not been sexually abused, which response by the nurse indicates effective teaching?

X-rays.

RN at a county health department receives a telephone call from a 22 YO who is 7 Ms pregnant. The caller reports that they are unable to afford food & asks where they should go to enroll in the Women, Infants, & Children (WIC) supplemental nutrition program. Which response demonstrates that the nurse understands the services offered by government agencies?

You've contacted the correct agency. The county health department can enroll you in the WIC program.

A community health nurse is describing the role of the local health department. Which item is appropriate for the nurse to​ include?

esponsibilities of local health departments include providing community disease monitoring and​ surveillance, reporting incidents of disease to state and federal​ authorities, and offering​ community-wide disease and injury prevention programs.

An individual who has experienced which type of trauma is likely to be most​ resilient?

natural disaster.

The nurse is assessing two​ clients: a23 YO who recently returned from overseas deployment c the military and a​ 68 YO who served in the military during the Vietnam War. Both clients have been diagnosed with PTSD. Which statement did the nurse likely record from the​ 68-year-old man?

​"I haven't had much of an appetite​ lately, and I keep forgetting important​ things." Older veterans may report more somatic​ complaints like loss of​ appetite, sleep​ disturbances, & cognitive​ problems, than younger veterans c PTSD. Older veterans are also less likely to have typical PTSD symptoms such as an exaggerated startle response and exhibit less​ depression, hostility, and guilt than younger veterans with PTSD.