MH: Exam 3 Practice Questions

A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

c. "How did this happen to you?" Obtaining the victim's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

A nurse talks with a person whose spouse died suddenly while jogging. Which is the appropriate statement for the nurse? a. "At least your spouse did not suffer." b. "It's better to go quickly as your spouse did." c. "The loss of your spouse must be very painful for you." d. "You'll begin to feel better after you get over the shock."

c. "The loss of your spouse must be very painful for you." The most helpful responses by others validate the bereaved person's experience of loss. Avoid banalities; they increase the individual's sense of isolation.

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

ANS: C The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should be the focus for crisis intervention? a. Possible mastectomy b. Disordered family communication c. Effects of the husband's infidelity d. Coping with the reaction to the daughter's events

The focus of crisis intervention is on the most recent problem—"the straw that broke the camel's back." The patient has coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurs only with the introduction of the daughter leaving college and moving.

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient 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. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

a. "Are you thinking of suicide?" The patient's words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment

A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components?Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

a. Keep a cell phone fully charged. c. Have the telephone number for the nearest shelter. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

After being notified that her husband died of heart failure, a wife approaches the nurse who cared for her husband. In the hospital hallway the wife shouts angrily, "He'd still be alive if you'd given him your undivided attention!" Select the nurse's best response. a. "I understand you're feeling upset. Let's go to our conference room, and I'll stay with you until your family comes." b. "Your husband's heart was severely damaged and could no longer pump. There's nothing anyone could have done." c. "I will call the nursing supervisor to discuss this matter with you." d. "It will be all right if you cry. Crying is a normal grief response." "I understand you're feeling upset. Let's go to our conference room, and I'll stay with you until your family comes."

a. "I understand you're feeling upset. Let's go to our conference room, and I'll stay with you until your family comes." When a bereaved family member behaves in a disturbed manner, the nurse should show patience and tact while offering sympathy and warmth. Moving the individual to a private area so as not to disturb others is important. The incorrect options are defensive, evasive, or placating.

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents?Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by "yes" or "no."

A terminally ill patient says, "I know I'm not going to get well, but still..." and the patient's voice trails off. Which response by the nurse would be therapeutic? a. "What do you hope for?" b. "No, you're not going to get well." c. "Do you have questions about what is happening?" d. "I'm happy you are being realistic about your future."

a. "What do you hope for?" This open-ended response is an example of following the patient's lead. It provides an opportunity for the patient to speak about whatever is on his or her mind. The incorrect options are not therapeutic; they block further communication, refocus the conversation, give advice, or suggest the nurse is uncomfortable with the topic.

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Acute phase b. Outward adjustment phase c. Long-term reorganization phase d. Anger phase

a. Acute phase The victim's response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term, or anger phase.

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

a. maintaining the airway. Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. d. Reassure the patient that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the patient to offer reassurance that the nurse is caring and compassionate.

a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patient's privacy may be compromised by the presence of family. The rape victim's anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child They have the greatest number of stressors

A child was abducted and raped. In the emergency department, this victim is confused and crying. Which personal reaction by the nurse could interfere with this victim's care? a. Anger b. Concern c. Empathy d. Compassion

a. Anger Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

a. Chronic low self-esteem, related to negative feedback from parents The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

a. Confusion and disbelief Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

Which assessment has priority when a nurse interviews a rape victim in the emergency department? a. Coping mechanisms the patient is using b. Patient's previous sexual experience c. Adequacy of interpersonal relationships d. Patient's history of sexually transmitted diseases

a. Coping mechanisms the patient is using Of the options listed, the priority assessment is the victim's coping mechanisms. The other options have little relevance.

An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

a. Dementia Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

When an emergency department nurse teaches a victim of the rape trauma syndrome about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

a. Development of fears and phobias c. Feelings of numbness d. Flashbacks, dreams These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long- term reorganization phase. Syncopal episodes are not expected.

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? (Select all that apply) a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

a. Difficulty using a cell phone d. Rapid speech e. Trembling Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

a. History of family violence An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation?Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care ABC

a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority

CHAPTER 22 A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychologic trauma? a. Threat to her life b. Memory of the event c. Being in a remote location d. Physical pain experienced

a. Threat to her life The psychologic trauma associated with rape is produced by a number of factors. Of the options given, the threat to life is by far the most traumatic aspect of the crisis. The other options may, however, add significantly to the trauma.

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity

a. Use accepting, nurturing, and empathetic communication techniques. Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

a. expresses frustration verbally instead of physically. The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.

The assumption most useful to a nurse planning crisis intervention for any patient is that the patient: a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has a high potential for self-injury.

a. is experiencing a state of disequilibrium. Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. The potential for self-violence or other-directed violence may or may not be a factor in crisis.

A victim of physical abuse by a domestic 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: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

a. name two community resources that can be contacted. The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

An adult has cared for a debilitated parent for 10 years. The parent's condition has recently declined, and the health care provider has recommended placement in a skilled care facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to: a. resolving the feelings associated with the threat to the person's self-concept b. maintaining the ability to identify situational supports in the community c. relying on the assistance from role models within the person's culture d. mobilizing automatic relief behaviors by the person

a. resolving the feelings associated with the threat to the person's self-concept The patient's crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution involves coming to terms with the feelings associated with this loss. Identifying situational supports is relevant but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but is not the primary factor associated with resolution in this case. Automatic relief behaviors are not helpful and are part of the fourth phase of crisis.

While conducting the initial interview with a patient in crisis, the nurse should: a. speak in short, concise sentences. b. convey a sense of urgency to the patient. c. be forthright about time limits of the interview. d. let the patient know the nurse controls the interview.

a. speak in short, concise sentences. Severe anxiety narrows perceptions and concentration. By speaking in short, concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient's anxiety. Letting the patient know who controls the interview or stating that time is limited is nontherapeutic.

A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on: a. supporting emotional security and reestablishing equilibrium b. offering a long-term resolution of issues precipitating the crisis c. promoting growth of the individual d. providing legal assistance

a. supporting emotional security and reestablishing equilibrium Strategies of crisis intervention are directed toward the immediate cause of the crisis and are aimed at bolstering the emotional security and reestablishing equilibrium, rather than focusing on underlying issues and long-term resolutions. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. Promoting growth is a focus of long-term therapy. Providing legal assistance might be applicable.

A woman whose husband is terminally ill says, "I don't want to cry in front of him. I don't want him to know how close he is to death or how sad I am." Which response by the nurse would be most therapeutic? a. "You're right to protect him at a time when he is so vulnerable." b. "He might be more reassured than disturbed by your tears." c. "It's important for you to know that time is running out." d. "You definitely need to be honest about your feelings."

b. "He might be more reassured than disturbed by your tears." Many people try to protect the dying person from experiencing emotions; however, emotional honesty is important to both the patient and the family. The patient may be reassured knowing that the family is facing the inevitable. Giving advice and making judgmental statements are not helpful.

After the death of his wife, a man tells the nurse, "I can't live without her. She was my whole life." Which is the nurse's most therapeutic reply? a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "Remember, she's no longer suffering." d. "Your friends will help you cope with this."

b. "Her death is a terrible loss for you." The correct response demonstrates the use of reflection, a therapeutic communication technique. A statement that validates the bereaved person's loss is more helpful than banalities and clichés; it signifies understanding. The other options are clichés

CHAPTER 20 A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurse's best initial statement to this patient. a. "Everything is going to be all right. You are here at the clinic, and the staff will keep you safe." b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c. "You need to try to stop crying so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate the use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance.

During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." What could the nurse say to assess personal coping skills? a. "What would you like us to do to help you feel more relaxed?" b. "In the past, how did you handle difficult or stressful situations?" c. "Do you think you deserve to have things like this happen to you?" d. "I can see you are upset. You can rely on us to help you feel better."

b. "In the past, how did you handle difficult or stressful situations?" The correct answer is the only option that assesses coping skills. The incorrect options offer unrealistic reassurance, are concerned with self-esteem, and ask the patient to decide on treatment at a time when he or she "cannot think clearly."

An appropriate question for the nurse to ask to assess situational support is: a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

b. "Who can be helpful to you during this time?" Only the correct answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event.

Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Adventitious c. Situational d. Organic

b. Adventitious An adventitious crisis is a crisis of disaster that is not a part of everyday life; it is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. Organic is not a type of crisis.

Which finding indicates the successful completion of an individual's grieving process? a. For 2 years, a person has kept the deceased spouse's belongings in their usual places. b. After 15 months, a widowed person realistically remembers both the pleasures and disappointments of the relationship with the spouse. c. Three years after the death, a person talks about the spouse as if the spouse were still alive and weeps when others mention the spouse's name. d. Eighteen months after the spouse's death, a person says, "I never cry or have feelings of loss even though we were always very close."

b. After 15 months, a widowed person realistically remembers both the pleasures and disappointments of the relationship with the spouse. The work of grieving is over when the bereaved can remember the individual realistically and acknowledge both the pleasure and disappointments associated with the loved one. The individual is then free to enter into new relationships and activities. The other options suggest unresolved grief.

Shortly after a man's wife dies, the man approaches the nurse who cared for his wife during her final hours of life and says angrily, "If you had given your undivided attention, she would still be alive." Which analysis applies? a. The comment summarizes the nurse's inadequacies. b. Anger is a phenomenon experienced during grieving. c. The patient had ambivalent feelings about his spouse. d. In some cultures, grief is expressed solely through anger.

b. Anger is a phenomenon experienced during grieving. Anger may protect the bereaved from facing the devastating reality of the loss. Anger expressed during mourning is not directed toward the nurse, personally, although accusations and blame may make him or her feel as though it is.

CHAPTER 21 A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse

b. Child and siblings are experiencing neglect. The child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

b. Collecting and preserving evidence d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

b. Have the patient fill out an abuse assessment screen. In this situation, the nurse should consider the possibility that the patient is a victim of domestic violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

b. Powerlessness The patient describes feelings of the lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not shown to be altered at this point.

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

b. Report the suspected abuse or neglect according to state regulations. Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

b. Reported c. Penetration f. Declined The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. "Reported" should be used instead of "alleged." "Penetration" should be used instead of "intercourse." "Declined" should be used instead of "refused."

After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

b. Risk for injury, related to partner's physical abuse when intoxicated Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.

A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

b. Risk of domestic abuse The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurse's advocacy role necessitates an assessment for domestic violence

An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mother's evening and night care. The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d.Positive feelings promote the development of sympathy for patients.

b. Strong negative feelings interfere with assessment and judgment. Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.

Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression. b. Teaching stress reduction techniques to a beginning student nurse. c. Assessing coping strategies used by a patient who has attempted suicide. d. Referring a patient with schizophrenia to a partial hospitalization program.

b. Teaching stress reduction techniques to a beginning student nurse. Primary crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary intervention.

A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is: a. suicidal b. anxious and fearful. c. misperceiving reality. d. potentially homicidal.

b. anxious and fearful. Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed.

A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." If this person's immediate family is unable to provide sufficient situational support, the nurse should: a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support. c. tell the patient, "You must be strong. Don't let this crisis overwhelm you." d. foster insight by relating the present situation to earlier situations involving loss.

b. ask what other relatives or friends are available for support. The assessment of situational supports should continue. Although the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic

A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

b. explain that washing would destroy evidence. No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

The mourning process is more difficult when the bereaved: a. was relatively independent of the deceased. b. has experienced a number of previous losses. c. accepts that death is expected for older adults. d. had few unresolved conflicts with the deceased.

b. has experienced a number of previous losses. Factors that have negative effects on the mourning process include a high dependency on the deceased, ambivalence toward the deceased, a poor or absent support system, a high number of past losses or other recent losses, poor physical or mental health, and young age of the deceased. Data do not support the incorrect options.

A person whose spouse died two years earlier tells friends, "I think I'll start going out socially, maybe even take someone to dinner." This comment best demonstrates that the individual is: a. denying the significance of the loss. b. in a period of resolution of grief. c. actively working through grief. d. experiencing intrusion.

b. in a period of resolution of grief. Toward the end of the grief process, the person renews his or her interest in people and activities. This behavior indicates resolution. At the same time, the person is released from the relationship with the deceased. The patient has progressed beyond grief. The patient is seeking to move into new relationships so that he or she is not alone.

A patient in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates the patient has made improvement? The patient: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

b. plans coping strategies for fearful situations. The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

b. provide referral information verbally and in writing. Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective

A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

b. provide written information concerning the physical and emotional reactions that may be experienced. All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

c. "You believe this would not have happened if you had not been alone?" A reflective communication technique is helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victim's perceived role and interfere with further discussion.

A patient diagnosed with metastatic brain cancer says, "I'm dying, but I'm still living. I want to be in control as long as I can." Which reply shows the nurse was actively listening? a. "Our staff will do their best to help you feel comfortable." b. "Most people do not know how to help and are afraid of death." c. "Your mind and spirit are healthy, although your body is frail." d. "You want people to stop focusing on your weaknesses."

c. "Your mind and spirit are healthy, although your body is frail." The patient is asking for acknowledgment that he or she is not totally sick; even in the terminal state, strengths and capabilities are present. The correct response provides that acknowledgment. The other responses are tangential.

A patient visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is _____________ weeks. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

c. 4 to 6 The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If the crisis is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration

A patient's fiancé died in an automobile accident several days ago. The patient reports crying and experiencing feelings of guilt and anger. This behavior is characteristic of which stage of acute grief? a. Denial b. Reorganization c. Development of awareness d. Preoccupation with the lost object

c. Development of awareness As denial fades, an awareness of the finality of the loss develops and is accompanied by painful feelings of loss, anger with others, and guilt for taking or not taking specific actions. Reorganization implies the movement toward healing. Denial is manifested by the inability to believe the reality of an event. Preoccupation with the lost object would involve the patient dwelling on thoughts of the deceased.

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

c. Emotional Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

An adult tells the nurse, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she's quitting college and moving in with her boyfriend." What is the priority nursing diagnosis? a. Fear, related to impending surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

c. Ineffective coping, related to perceived loss of daughter This nursing diagnosis is the priority because it reflects the precipitating event associated with the patient's crisis. Data are not present to make the other diagnoses of Deficient knowledge, Fear, or Impaired verbal communication.

After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Adventitious

c. Maturational Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. No classification called reactive crisis exists. Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent crimes disrupt coping styles.

Which agency provides coordination in the event of a terrorist attack? a. ANS: BThe correct answer is the only option that assesses coping skills. The incorrect options offer unrealistic reassurance, are concerned with self-esteem, and ask the patient to decide on treatment at a time when he or she "cannot think clearly." DIF: Cognitive Level: Application REF: Page: 391|Page: 394TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity a. U.S. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

c. National Incident Management System (NIMS) The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

c. Physical The assessment of physical abuse is supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

c. Situational A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists.

At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me feel like my life is back in balance." The nurse responds, "I think it would be worthwhile to have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates a need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patient's feelings of dependency

c. The nurse is having difficulty terminating the relationship. The nurse's remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is on the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient's need for continuing support is not demonstrated in the scenario. The scenario does not describe dependency needs.

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

c. Women's shelter Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup

c. bite marks Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence

A nurse working a rape telephone hotline should focus communication to: a. arrange long-term patient counseling. b. provide callers with a sympathetic listener. c. explain immediate steps that a victim of rape should take. d. obtain information to relay to the local police.

c. explain immediate steps that a victim of rape should take. The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.

c. helping the victim feel safe. The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might refuse to have evidence collected or to involve law enforcement.

An adult who was widowed 18 months ago says, "I can now remember good times we shared without getting upset. Sometimes I even think about the disappointments. I've become accustomed to sleeping in our bed alone." The work of mourning: a. is beginning. b. is progressing abnormally. c. is at or near completion. d. has not begun.

c. is at or near completion. The work of mourning has been successfully completed when the bereaved can remember both the positive and negative memories about the deceased and when the task of restructuring the relationship with the deceased is completed.

An adult seeks counseling after the spouse is murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b. "What resources do you need to help you cope with this situation?" c. "Do you have enough support from your family and friends?" d. "Are you having thoughts of hurting yourself or others?"

d. "Are you having thoughts of hurting yourself or others?" The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options are important but not the highest priority.

A family of a terminally ill patient asks the nurse, "What can we say when our family member mentions death is coming soon?" Which response could the nurse suggest? a. "We think you will be around for a long time." b. "We don't want you to give up trying to get well." c. "We don't think we're ready to talk about this yet." d. "We feel so sad when we think of life without you."

d. "We feel so sad when we think of life without you." This response is emotionally honest. It will allow the family opportunities to express emotions and further resolve issues in the relationship and explore end-of-life developmental opportunities. The incorrect options are evasive.

A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event? a. "Tell me why you were crying" b. "How did your wrist get injured?" c. "How can I help you feel more comfortable d. "What was happening just before you started to feel this way?"

d. "What was happening just before you started to feel this way?" A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking "why" questions is a poor communication technique.

A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identifying measures useful to help improve the couple's communication b. Discussing the patient's feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by, "I can't take it anymore!

d. Clarifying what the patient means by, "I can't take it anymore! During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

d. Denial The patient's statements reflect the use of the ego defense mechanism denial. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patient's statements do not reflect somatic symptoms, repression, or projection.

A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents

d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet helps anxious parents and their children to unite. Preventing parents from uniting with their children would further incite the situation.

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

d. Desire to humiliate or control others Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

d. Document injuries with a body map. Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy b. Case manager whose patients are seriously mentally ill and are being cared for at home c. Health care employee who worked 8 hours at the information desk of an intensive care unit d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store Although each of the individuals mentioned experiences job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to victims of trauma.

Which communication technique is used more in crisis intervention than traditional counseling? a. Role modeling d. Giving direction c. Information giving d. Empathic listening

d. Giving direction The nurse working in crisis intervention must be creative and flexible in looking at the patient's situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape victim advocate

d. Patient agrees to keep a follow-up appointment with the rape victim advocate Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

d. Physical injuries The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

Which scenario is an example of an adventitious crisis? a. Death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55-year-old d. Riot at a rock concert

d. Riot at a rock concert The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

A patient newly diagnosed with pancreatic cancer says, "My father also died of pancreatic cancer. I took care of him during his illness. I can't go through that." Select the highest priority nursing diagnosis. a. Anticipatory grieving b. Ineffective coping c. Ineffective denial d. Risk for suicide

d. Risk for suicide The patient's statement has a subtle message of suicide. Suicide is a risk for people with major losses, including terminal disease. The nurse will need to monitor the suicide risk vigilantly. The other diagnoses may apply but are lower priority.

A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

d. Severe Anxiety is the result of a personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. "Weak" is not a level of anxiety. Mild and moderate levels of anxiety allow the patient to function at a higher level.

A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

d. Support the victim to separate issues of vulnerability from blame. Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident

CHAPTER 25 A nurse working with a person whose spouse recently died uses cheer and humor to lift the person's spirits. At one point, the widowed person smiles briefly. What analysis of this scenario is correct? a. The nurse's technique was successful. b. Use of humor should be added to the plan of care. c. Approach may prove useful in other, similar situations. d. The nurse needs supervision; the communication technique was not appropriate.

d. The nurse needs supervision; the communication technique was not appropriate. Clinical supervision will review the nurse's actions and thoughts and help the nurse arrive at a more therapeutic approach. Attempts at cheering up a patient who is depressed serve only to emphasize the disparity between the patient's mood and that of others. Active listening should be the technique used by the nurse. The incorrect options suggest the approach is therapeutic when it is not.

After the death of a spouse, an adult repeatedly says, "I should have made him go to the doctor when he said he didn't feel well." This individual is experiencing: a. preoccupation with the image of the deceased. b. sensations of somatic distress. c. anger. d. guilt.

d. guilt. Guilt is evident by the bereaved person's self-reproach. Preoccupation refers to dwelling on images of the deceased. Somatic distress would involve bodily symptoms. Anger is not evident from data given in this scenario.

A recently widowed patient tells the health care provider, "I have so much epigastric discomfort. I wonder if I have an ulcer." Diagnostic tests are negative. The symptom demonstrates: a. early reorganization behavior b. disorganization and depression c. preoccupation with the deceased d. normal phenomenon of mourning

d. normal phenomenon of mourning Sensations of somatic distress are often experienced during the acute stage of grieving. They include tightness in the throat, shortness of breath, exhaustion, and pain or sensations such as those experienced by the dead person.

A nurse cares for a rape victim who received flunitrazepam (Rohypnol) from the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

d. respiratory depression. Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

A child drowned while swimming in a local lake four years ago. Which behavior indicates that the parents are effectively coping with their loss? The parents: a. prohibit their other children from going swimming. b. keep a place set for the dead child at the family dinner table. c. keep their child's room exactly as the child left it 4 years ago. d. throw flowers on the lake at each anniversary date of the accident.

d. throw flowers on the lake at each anniversary date of the accident. The loss of a child is among the highest risk situations for dysfunctional grieving. The parents who throw flowers across the lake on each anniversary date of the accident are effectively using a ritual to express their feelings openly. The other behaviors indicate the parents are isolating themselves or denying their feelings or both.

After completing the contracted number of visits to the crisis clinic, an adult says, "I've emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I'm benefiting from a support group." The nurse can evaluate the patient's feelings about the care received as: a. not at all satisfied b. somewhat satisfied c. moderately satisfied d. very satisfied

d. very satisfied The patient mentions a number of indicators that suggest a high degree of satisfaction with the Nursing Outcomes Classification of patient satisfaction: psychologic care. No indicators express low-to-moderate satisfaction.