PSYCH UNIT 2
Which type of child abuse can be most difficult to treat effectively? A. Emotional B. Neglect C. Physical D. Sexual
A. Emotional
Which of the following statements would indicate that teaching about naltrexone (ReVia) has been effective? A. "I'll get sick if I use heroin while taking this medication." B. "This medication will block the effects of any opioid substance I take." C. "If I use opioids while taking naltrexone, I'll become extremely ill." D. "Using naltrexone may make me dizzy."
B. "This medication will block the effects of any opioid substance I take."
The nurse has provided an in-service program on impaired professionals. She knows that teaching has been effective when staff identify which of the following as the greatest risk for substance abuse among professionals? A. Most nurses are codependent in their personal and professional relationships. B. Most nurses come from dysfunctional families and are at risk for developing addiction. C. Most nurses are exposed to various substances and believe they are not at risk to develop the disease. D. Most nurses have preconceived ideas about what kind of people become addicted.
C. Most nurses are exposed to various substances and believe they are not at risk to develop the disease.
A 5-year-old child has been removed from the home because of sexual abuse by the stepfather. What information should the nurse include when teaching the child's mother about possible consequences the child might experience? A. Since the child was removed from the home at an early age, no long-term consequences are expected B. Because the abuser was someone well known by the child, the situation will be less traumatic for the child. C. The child is at current risk for developing depression and will remain so in the future D. Once an adult, the child should be counseled not have children, as the child will become an abuser
C. The child is at current risk for developing depression and will remain so in the future Rationale: Among other frequent consequences are self-esteem disturbances, feelings of guilt, sexual acting out behaviors, post traumatic stress disorders (PTSD), and self-mutilation behaviors. There are many long-term consequences of child abuse. Abuse is more devastating if the abuser is an individual the child knew and trusted. It is true that many victims of child abuse do themselves become abusers in the future, but one cannot predict that this will happen in all cases. Many victims of child abuse are able to have normal, healthy, nonabusive parent-child relationships
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? A. "I no longer feel that I deserve the beatings my husband inflicts on me" B. "My attendance at the meetings has helped me to see that i provoke my husbands violence" C. "I enjoy attending the meetings because they get me out of the house and away from my husband" D. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics"
A. "I no longer feel that I deserve the beatings my husband inflicts on me" Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it examplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option B is incorrect because the nonalcoholic partner should no feel responsible when the spouse loses control. Option C indicates that the group is viewed as an escape, not as a place to work on issues. Option D indicates that the wife remains codependent.
A newly licensed nurse asks an experienced nurse about theories related to violent behaviors toward others. The experienced nurse should respond by making which statements? Select all that apply. A. "The underpinnings of social learning theory lay in the idea that violent behavior is related to the perpetrator's need for control and power" B. "There is no etiologic basis for violent behavior toward others" C. "Poor impulse control may be one reason for violent behavior" D. "Feminist theory states that it is due to the physiology of the male gender" E. "The male response theory states that women provoke men, and that women are responsible for the abuse"
A. "The underpinnings of social learning theory lay in the idea that violent behavior is related to the perpetrator's need for control and power" C. "Poor impulse control may be one reason for violent behavior" Rationale: Social learning theory states that society's attitude about the use of coercion and force supports levels of violence. Violent behavior is a means to exert power and control over others. Impulse control problems may play a factor in violent behavior. There are many theories for violent behavior. There are many theories for violent behavior, these include intrapersonal theory, interpersonal theory, social learning theory, and gender bias theory. The feminist theory outlines the idea that economic activities see the women as powerless and subservient to men. There is no response theory regarding men.
A female client comes to an urgent care clinic and says, "I've just been raped." What should the nurse do? (Select all that apply) A. Allow the client to express whatever she wants. B. Ask the client if staff can call a friend or family member for her. C. Offer the client coffee, tea, or whatever she likes to drink. D. Get the examination completed quickly to decrease trauma to the client. E. Provide the client privacy—let her go to a room to make phone calls. F. Stay with the client until someone else arrives to be with her.
A. Allow the client to express whatever she wants. B. Ask the client if staff can call a friend or family member for her. F. Stay with the client until someone else arrives to be with her.
A nurse is working with a client detoxifying from alcohol who exhibits coarse hand tremors and diaphoresis. What should be the priority interventions by the nurse? Select all that apply. A. Assess level of consciousness B. Explain the concepts of withdrawal to the client C. Administer prescribed thiamine and folic acid D. Determine the most recent blood alcohol level E. Assess vital signs
A. Assess level of consciousness E. Assess vital signs Rationale: Assessing the clients level of consciousness is of high priority in monitoring a client experiencing withdrawal as part of withdrawal management. The nurse should assess vital signs to recognize possible signs of autonomic hyperactivity that is a part of alcohol withdrawal delirium. The nurse should be able to recognize and respond to the clinical signs of increasing intensity of withdrawal symptoms. Because the client is in active withdrawal, this is not the time to teach the client. The priority is on maintaining physiological functioning and environmental safety. Thiamine and folic acid may be prescribed for the client who is withdrawing from alcohol, but they are used to treat complications of alcoholism, not to manage the acute symptoms of withdrawal. This can only be done with a drug that is cross-tolerant with alcohol. Determining the most recent blood alcohol level is inappropriate, as it would not provide current data.
Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which of the following nursing assessments is essential before giving a dose of this medication? A. Assessing the client's blood pressure B. Determining when the client last used an opiate C. Monitoring the client for tremors D. Completing a thorough physical assessment
A. Assessing the client's blood pressure
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want anymore treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? A. Call the nursing supervisor B. Call security to block all exit areas C. Restrain the client until the health care provider (HCP) can be reached D. Tell the client that the client cannot return to this hospital again if the client leaves now
A. Call the nursing supervisor Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have the right to health care and cannot be told otherwise.
Examples of child maltreatment include.... (Select all that apply). A. Calling the child stupid for climbing on a fence and getting injured. B. Giving the child a time-out for misbehaving by hitting a sibling. C. Failing to buy a desired toy for Christmas. D. Spanking an infant who won't stop crying. E. Watching pornographic movies in a child's presence. F. Withholding meals as punishment for disobedience.
A. Calling the child stupid for climbing on a fence and getting injured. D. Spanking an infant who won't stop crying. E. Watching pornographic movies in a child's presence. F. Withholding meals as punishment for disobedience.
A nurse is teaching a group of clients about addiction. One client says he can stop drinking whenever he wants. The nurse concludes that this client does not yet understand that addiction is a disease in which individuals primarily lose ability to do which of the following? A. Control addictive and impulsive behaviors B. Recognize that addictive behavior is harmful to themselves and others C. Act sober even if they are not D. Think logically about their addictive behaviors
A. Control addictive and impulsive behaviors Rationale: The key symptom of addiction is impaired control, or the inability to control, or regulate, ones addictive behavior. While individuals with addiction fo not change their behavior because of negative consequences sustained, it is not that they do not recognize the consequences. Rather, they continue the addictive behavior in spite of consequences experienced. Acting sober when intoxicated is an addictive behavior. In addition to loss of control, the individual with addiction is not able to view the addictive behaviors realistically or logically. The individual frequently uses the defense mechanisms of denial, rationalization, and projection.
A pediatric client has severe injuries to the abdomen. The nurse should suspect child abuse if the parents do which of the following? A. Delay seeking treatment for the child's injuries B. Give a very detailed description of the events prior to the injuries C. Exhibit an anxious and concerned attitude D. Encourage the child to explain the injuries
A. Delay seeking treatment for the child's injuries Rationale: A delay in seeking treatment for serious injuries is an indication of abuse. Vague descriptions of the injuries with little detail are more likely to indicate abuse than a detailed description. Anxiety and concern on the parents' part would be expected. Preventing the child from explaining the injuries and not encouraging explanation would be an indication of abuse.
A client comes to day treatment intoxicated, but says he is not. The nurse identifies that the client is exhibiting symptoms of A. Denial. B. Reaction formation. C. Projection. D. Transference.
A. Denial
A client staggers when walking into the day treatment center with an intense odor of alcohol and insists that he has not consumed any alcohol. The nurse concludes that this behavior constitutes which of the following? A. Denial B. Rationalization C. Transference D. Countertransference
A. Denial Rationale: It would not be unusual for a client who has severe addiction to come to day treatment intoxicated and deny it. Denial would cause a client to insist he or she is not intoxicated, or doesn't have a problem with alcoholism, despite concrete evidence of the problem. Rationalization is a frequently used defense mechanism of the individual with alcoholism, but I'd it were bring used, the client would offer an explanation for the odor or alcohol. Transference is the unconscious princess of displacing feelings for significant people in the past onto the nurse in the present relationship. Countertransference is the nurse's emotional reaction to clients based on feelings for significant people in the nurse's past
An older adult has been admitted to the hospital for dehydration. The client is poorly dressed, has body odor, appears unkempt, and has numerous unexplained bruises. The client also states that he has not been receiving his medications from his caregiver. What should be the nurse's priority initial action? A. Determine if the client is experiencing abuse or neglect B. Contact the appropriate elderly protective services agency C. Explore methods of rehydration attempted at home D. Inquire about medications the client is taking
A. Determine if the client is experiencing abuse or neglect Rationale: Initial observations of dehydration, unexplained bruises, and poor hygiene indicate possible abuse or neglect. The possibility of neglect should be assessed immediately. It is premature for the nurse to report the suspected abuse before more data are gathered. Exploring the rehydration methods attempted at home can be done after further investigating the possibility of abuse, although instituting rehydration would be important. Determining medications the client has been taking at home is part of routine care and is not the highest priority for this client.
Women in battering relationships often remain in those relationships as a result of faulty or incorrect beliefs. Which of the following beliefs is valid? A. If she tried to leave, she would be at increased risk for violence. B. If she would do a better job of meeting his needs, the violence would stop. C. No one else would put up with her dependent clinging behavior. D. She often does things that provoke the violent episodes.
A. If she tried to leave, she would be at increased risk for violence.
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? A. Information regarding shelters B. Instructions regarding calling the police C. Instructions regarding self-defense classes D. Explaining the importance of leaving the violent situation
A. Information regarding shelters Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violence is important, but the specific plan is necessary
A client admitted for chest pain related to cocaine abuse states, "This is nothing but a little indigestion. What's all the fuss about?" This client is using which defense mechanism? A. Minimization B. Denial C. Rationalization D. Projection
A. Minimization
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. A. Monitor vital signs B. Provide a safe environment C. Address hallucinations therapeutically D. Provide stimulation in the environment E. Provide reality orientation as appropriate F. Maintain NPO (nothing by mouth) status
A. Monitor vital signs B. Provide a safe environment C. Address hallucinations therapeutically E. Provide reality orientation as appropriate Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
What information would the student nurse include in the report about the 12-step program of Alcoholic Anonymous (AA)? Select all that apply. A. People learn to change negative attitudes and behaviors into positive ones B. Once an individual learns how to be sober, he or she can graduate from attending meetings C. Once an individual has achieved sobriety, he or she continues to be at risk for relapse into drinking. D. Acceptance of being an alcoholic will prevent urges to drink, since it represents giving up one's denial E. A higher power will protect individuals if they feel like using
A. People learn to change negative attitudes and behaviors into positive ones C. Once an individual has achieved sobriety, he or she continues to be at risk for relapse into drinking. Rationale: AA teaches that a client with alcoholism can never safely return to social drinking and that total abstinence is the only course in treating the addiction. People learn how to develop positive attitudes and behaviors to replace negative ones. When sobriety had been achieved, people don't "Graduate"; they stay and help others achieve sobriety. Acceptance and higher power are active consents in urges to drink and does not guarantee sobriety.
An 18-month-old client is scheduled for a minor surgical procedure. The client has numerous large bruises of different stages over the back and buttocks. The mother states that the child must have fallen down while playing alone but cannot provide specific information. How should the nurse evaluate this situation? A. Possible child abuse B. Immature parenting C. Normal findings in an 18-month-old D. Indications of tissue fragility
A. Possible child abuse Rationale: The number, extent, and location of the bruises, and the mother's vague explanations of the injuries, indicate possible child abuse. The mother's statement that the child was unsupervised while playing also indicates possible child abuse. Children of this age should be supervised during play. No information is given about the level of maturity of the mother, but it appears that the parenting is inadequate. While it is true that an 18-month-old is unsteady and will fall often, the nurse would not expect to see numerous large bruises of different stages confined to the back and hips. If tissue fragility was present in this child, it would not be limited to the back and buttocks.
A nurse is counseling an extremely distressed victim immediately after a sexual assault. What should be the nurse's most important initial intervention? A. Reassure the victim that the sexual assault was not her fault B. Ask the client to provide a sample of pubic hair for the evidence kit C. Collect a serum specimen for pregnancy testing D. Teach the client about the risk for sexually transmitted infections
A. Reassure the victim that the sexual assault was not her fault Rationale: Victims of sexual assault often feel guilty and responsible for the assault. It is essential for the nurse to reassure the client that it was not the client's fault. Collecting a sample for the evidence kit would proceed only after reassuring the client and obtaining permission to gather evidence. Collecting a specimen for pregnancy testing would be a secondary intervention after the client is calmer. Teaching the client about the risk for sexually transmitted infections would be appropriate once the other interventions are completed.
A pregnant women comes to the emergency department with bruises on her arms and abdomen after a fight with her boyfriend. What is most important for the nurse to address when teaching this client? A. Risks of pregnancy complications caused by abuse B. Assertiveness training to deal with the boyfriend C. Childbirth classes to prepare for the birth D. Instructions on the use of resources available to her
A. Risks of pregnancy complications caused by abuse Rationale: It is vital that the client understand that the pregnancy may be in danger form the abuse. Among possible consequences of abdominal beating of a pregnant woman are miscarriage, abruptio placentae, fetal loss, premature labor, and fetal or maternal fracture. Assertiveness training may be useful in the future but is not the immediate priority. Childbirth classes will be helpful to prepare for the birth, but the client's physiological and safety needs must come first. The client will need resources, but the client must first understand the risks to herself and the pregnancy in order to maintain safety.
The nurse is caring for a client who comes to the emergency department with bruises on the face, a cracked tooth, and back pain. She voices concern about the safety of her pets and children, and her ability to enroll in her college as she plans. The nurse replies by examining which of the following? Select all that apply. A. She is correct that her pets may be at risk for injury or death from her spouse B. Her pets are safe; there is no correlation between interpersonal violence and injury to pets C. Her children are safe; there is no correlation between spousal violence and injury to children D. It is probable that her husband may try to sabotage her career goals E. She is correct that her children may be at risk for abuse
A. She is correct that her pets may be at risk for injury or death from her spouse D. It is probable that her husband may try to sabotage her career goals E. She is correct that her children may be at risk for abuse Rationale: The client's pets may be at risk for injury or death from the abusive spouse. A spouse who is abusive may try to sabotage the client's career goals. The children may also be at risk for abuse; there is a correlation between spousal violence and injury to children. The pets are not necessarily safe. The children of a client who has been abused cannot be considered to be safe.
The nurse determines that a client diagnosed with addiction understands the information provided about addiction when the client makes which statements? Select all that apply. A. "Addiction is a moral problem" B. "Addiction is a medical illness" C. "Addiction is a behavioral habit" D. "Addiction is an emotional attachment" E. "Addiction is difficult to cure"
B. "Addiction is a medical illness" C. "Addiction is a behavioral habit" D. "Addiction is an emotional attachment" Rationale: Alcoholism was officially listed as a disease in 1956, and Jellinek's identification of the four phases of disease progression in 1960 reinforced the disease concept ("addiction is a medical illness"). Addiction includes behavioral habits and emotional attachment, but it is seen first as a medical disease. Although alcoholism has been recognized as a disease for approximately 50 years, many members of the general public continue to view addiction as a moral weakness. Addiction experts do not consider that addiction can be cured. Instead, they consider it a chronic medical disease that can be managed.
A nurse is working on a neurological unit. A client with three young children is unconscious and has sustained a traumatic brain injury from a severe beating. Another staff nurse on the unit states, "She was stupid for staying in the relationship. She deserved it." What is the most appropriate responses by the nurse? Select all that apply. A. "Yes, she has a lot of family and friends whom she could have gone to" B. "One reason she may have stayed is because of traumatic bonding" C. "One reason she may have stayed is the fear of losing her children" D. "Women may stay in violent relationships due to fear, helplessness, guilt, or shame" E. "Maybe she has come to think violence is acceptable"
B. "One reason she may have stayed is because of traumatic bonding" C. "One reason she may have stayed is the fear of losing her children" D. "Women may stay in violent relationships due to fear, helplessness, guilt, or shame" E. "Maybe she has come to think violence is acceptable" Rationale: There are several reasons why women stay in abusive relationships. For example, traumatic bonding, which his where the client has hope and is looking for meaning in relationships. The abuser may threaten to kill or hurt the children, or she may have a fear of losing custody. Thinking that violence is acceptable is known as learned helplessness, whereby the victim thinks she has no control, and begins to think of violence as an acceptable way of life. Women may stay in violent relationships due to fear, guilt, shame, hope, or financial or emotional dependence. Agreeing and stating that the client has a lot of family and friends she could have gone to is incorrect. The nurse must put all judgements aside and understand the theoretical reasons fro why women stay in abusive relationships; in addition, many victims are socially isolated due to being controlled by their spouse.
The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? A. "Why don't you tell your spouse about this?" B. "What do you find difficult about this situation?" C. "This is not the best time to make that decision" D. "I agree with you. You should get out of this situation"
B. "What do you find difficult about this situation?" Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implied that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide an explaintion.
What is the best response by the nurse to a client being treated at an addiction center who questions why his 13-year-old son needs to participate in the family sessions, since he has not seen his father drinking? A. "Your son probably knows that you are an alcoholic" B. "Your son has probably seen changes in you when you were drinking" C. "It's good that you have concern for your underage son" D. "13-year-olds are old enough to start learning about the effects of alcohol"
B. "Your son has probably seen changes in you when you were drinking" Rationale: Stating that the son has probably seen changes in the client when drinking presents reality to the client in a matter-of-fact, informative way. It created an opportunity for the nurse to help the client see that the parent-child relationship has no doubt been impacted by the addiction. Stating that the son probably knows the client is an alcoholic applies a label to the client (an alcoholic), although the information it is conveying is accurate. Telling the client it's good that he has concern for his son offers approval or praise, and it allows the client to feel like a protective and good parent, instead of a parent whose behavior has impacted negatively on the son. Stating that the son is old enough to learn about the effects of alcohol removes the personal focus that is necessary to help the parent who is addicted recognize the impact of the addiction on the son.
Which of the following is the best action for the nurse to take when assessing a child who might be abused? A. Confront the parents with the facts, and ask them what happened. B. Consult with a professional member of the health team about making a report. C. Ask the child which of his parents caused this injury. D. Say or do nothing; the nurse has only suspicions, not evidence.
B. Consult with a professional member of the health team about making a report.
Which of the following would the nurse recognize as signs of alcohol withdrawal? (Select all that apply) A. Blackouts B. Diaphoresis C. Elevated blood pressure D. Lethargy E. Nausea F. Tremulousness
B. Diaphoresis C. Elevated blood pressure E. Nausea F. Tremulousness
The nurse would recognize which of the following drugs as central nervous system depressants? (Select all that apply) A. Cannabis B. Diazepam (Valium) C. Heroin D. Meperidine (Demerol) E. Phenobarbital F. Whiskey
B. Diazepam (Valium) E. Phenobarbital F. Whiskey
Which skill training should the nurse plan for a group of adolescent clients diagnosed with alcoholism in order to assist them in a relapse prevention program? A. Critical thinking skills B. Drinking refusal skills C. Problem solving skills D. Communication skills
B. Drinking refusal skills Rationale: The quality of an adolescent's recovery environment can be helpful or hurtful to someone attempting to maintain sobriety. Friends or acquaintances may encourage a recovering individual to use, so drinking refusal skills are important to learn. The recovering adolescent may want to refuse but not know how. Behavioral rehearsal, such as saying "no thanks" to an offer to engage in addictive behavior, can increase a recovering individual's confidence. Critical thinking skills will not help the adolescent to refuse a drink. Problem solving skills are generally useful but are not specific to drink refusal. Communication skills are generally useful but not as helpful as skills directly related to refusing to drink.
Which of the following behaviors would indicate stimulant intoxication? A. Slurred speech, unsteady gait, impaired concentration B. Hyperactivity, talkativeness, euphoria C. Relaxed inhibitions, increased appetite, distorted perceptions D. Depersonalization, dilated pupils, visual hallucinations
B. Hyperactivity, talkativeness, euphoria
A mother brings in an 8-month-old infant who is having difficulty breathing. The nurse assesses bleeding in the baby's retinas. The mother states that the child was being cared for by the father while the mother was out of the house. What is the most appropriate initial response of the nurse? A. Question the mother about the events prior to the respiratory distress. B. Identify this situation as a medical emergency C. Inform the mother that the period of greatest danger has passed D. Report the situation to the children's protective services agency
B. Identify this situation as a medical emergency Rationale: The respiratory distress and retinal bleeding are symptoms of shaken baby syndrome and represent a medical emergency. The child will continue to be at grave risk until the cerebral and ocular bleeding subsides. The events leading up to the distress are relevant but secondary at this time. Informing the mother that the greatest danger period has passed is inaccurate, because the child will continue to be at grave risk until the bleeding subsides. Reporting the incident to CPS is important, but at this time is secondary to providing emergency care to the child.
Which of the following assessment findings might indicate elder self-neglect? A. Hesitancy to talk openly with nurse B. Inability to manage personal finances C. Missing valuables that are not misplaced D. Unusual explanations for injuries
B. Inability to manage personal finances
When caring for a client with an opiate overdose, the nurse will anticipate which antagonist to be ordered? A. Disulfiram B. Naloxone C. Diazepam D. Bupropion
B. Naloxone Rationale: Naloxone (Narcan) is a narcotic antagonist that displaces previously administered narcotic analgesics from CNS receptors
The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret this behavior? A. Signs of depression B. Reactions to a devastating event C. Evidence that the client is a high suicide risk D. Indicative of the need for hospital admission
B. Reactions to a devastating event Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate an expected reaction.
A nurse is teaching a class on domestic violence to high school students. Which statement by a student would indicate to the nurse that further teaching is needed? A. "Violence often begins in a dating relationship" B. "The abuser will often apologize and promise to stop" C. "If you are educated and have money, abuse does not happen" D. "Abusers are often excessively jealous and possessive"
C. "If you are educated and have money, abuse does not happen" Rationale: Education and money do not make people immune to violence. It crosses all socioeconomic lines. Violence often begins in dating relationships. It is estimated the 30-40% of college students, and 10-20% of high school students are in abusive relationships. As part of a predictable cycle of violence, abusers typically apologize and promise to stop. However, the reality is that the level of abuse generally intensifies with the passage of time. Abusers are often excessively jealous and possessive. They control the victims life and isolate the vitcim from outside family or social contacts.
A client comes to the emergency department with a broken wrist and severe bruises inflicted by a beating by an intimate partner. The client states an intention to remain in the relationship at this time. What is the most appropriate response by the nurse? A. "You need to leave the relationship" B. "I will call a lawyer for you if you wish" C. "Let's develop a safety plan for repeated violence" D. "Here is a list of services that can help you"
C. "Let's develop a safety plan for repeated violence" Rationale: The client's safety is of utmost importance. If returning to the violent environment, it is urgent for the client to have a safety plan. Instructing the client to leave the relationship will not help is the client is not ready to do so. Additionally, the nurse should assist the client to make her own decision, rather than trying to impose personal views on the client. Providing information about legal assistance is appropriate, but it is secondary to assisting the client to plan for personal safety. Providing a list of services that are available is appropriate but would be secondary to assisting the client to plan for personal safety.
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? A. "You need to try to be realistic. The rape did not just occur." B. "It will take some time to get over these feelings about your rape." C. "Tell me more about the incident that causes you to feel like the rape just occurred." D. "What do you think that you can do to alleviate some of your fears about being raped again?"
C. "Tell me more about the incident that causes you to feel like the rape just occurred." Rationale: The correct option allows the client to express her ideas and feelings more fully and portrays a non-hurried, non-judgemental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option A immediately blocks communication. Option B places the clients feelings on hold. Option D places the problem solving totally on the client.
An adult survivor of child abuse states, "Why couldn't I make him stop the abuse? If I were a stronger person, I might have been able to make him stop. Maybe it was my fault he abused me." Based on this data, which would be the most appropriate priority nursing concern? A. Inability of family to cope B. Social Isolation C. Chronic low self-esteem D. Anxiety
C. Chronic low self-esteem Rationale: Inappropriate self-blame and feelings that a child could have stopped an adult's abuse indicate a low self-esteem. An inability of the family to cope is not the focus; the client is the focus. There is no indication that the client is socially isolated, although this could be a possible concern for adult survivors of abuse. The client's statements do not directly reflect anxiety.
The client tells the nurse that she takes a drink every morning to calm her nerves and stop her tremors. The nurse realizes the client is at risk for A. An anxiety disorder. B. A neurologic disorder. C. Physical dependence. D. Psychologic addiction.
C. Physical dependence
Which of the following is true about domestic violence between same-sex partners? A. Such violence is less common than that between heterosexual partners. B. The frequency and intensity of violence are greater than between heterosexual partners. C. Rates of violence are about the same as between heterosexual partners. D. None of the above.
C. Rates of violence are about the same as between heterosexual partners.
A 5-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse's assessment reveals bruises in the child's genital and rectal areas. The mother reports that she has left the little girl with her boyfriend the night before. Which action should be the nurse's first priority with this client? A. Obtain a urine sample to confirm a UTI B. Teach the mother about symptoms of UTI C. Report suspected sexual abuse to protective services D. Assess the child for other health problems
C. Report suspected sexual abuse to protective services Rationale: The child's examination shows probable signs of sexual abuse, which must be reported. Nurses are mandated reporters of suspected child abuse. Obtaining a urine sample would be a secondary priority after fulfilling legal responsibilities. Assessing the child for other health problems would be appropriate once the presenting problem has been addressed. Teaching the mother about UTI symptoms would be appropriate once the child has been cared for.
Which of the following is the most likely treatment sequence for a client recovering from alcohol abuse who tells the nurse that she is very depressed and has a hard time staying sober? A. Depression before the sobriety issue B. Sobriety issue before the depression C. Sobriety issue and depression at the same time D. Depression after the sobriety issue has been resolved
C. Sobriety issue and depression at the same time Rationale: The sobriety issue and depression are treated at the same time. This client will likely be dually diagnosed with alcoholism and depression. The nurse should recognize that current standards of addiction practice call for the substance abuse disorder and the psychiatric disorder to be treated simultaneously. Depression would not be treated before the sobriety issue. The sobriety issue would would not be treated before the depression. Treatment for depression would not be delayed until the sobriety issue has been resolved, because addiction is not a problem that is "resolved".
A client says "I have a very small drink every morning to calm my nerves and stop my hands from trembling." The nurse should conclude that this client is describing which state? A. An anxiety disorder B. Tolerance C. Withdrawal D. Alcohol abuse
C. Withdrawal Rationale: Taking a drink in the morning to steady one's nerves is a sign of physical dependence and is done to avoid withdrawal symptoms. Tremors are one of the ten symptoms of alcohol withdrawal listed in the CIWA assessment of alcohol symptoms. People with anxiety may have tremors, but the tremors would occur throughout the day. Tolerance is not indicated because the client does not describe needing to have a larger drink in order to prevent symptoms. This client has clearly progressed from alcohol abuse to alcohol dependency.
A nurse is caring for a client who is being treated for migraine headaches. Upon physical exam, the nurse assesses old scars on the clients arms and legs. The client confides childhood memories of sexual abuse by the father. What should be the nurse's immediate response? A. "Tell me more about your migraines" B. "How did you get the scars?" C. "How old were you when the abuse stopped?" D. "Are you comfortable discussing the abuse?"
D. "Are you comfortable discussing the abuse?" Rationale: The migraines may be the presenting problem, but the client is indicating a need to discuss the abuse. A nonjudgemental approach considering the client's comfort level would be the best way to prevent the client from feeling guilt and shame. The nurse should acknowledge the client's comment and explore what the client would like to share at this time. Asking how the client got the scars and how old she or she was when the abuse stopped is secondary at this point. The client is indicating a readiness to express feelings, not provide data.
A client who has alcohol dependence and cardiomyopathy tells the nurse that she is certain that her family and friends are against her. The client goes on to say, "They stay on my back about my drinking and say I could die from it." What is the best response by the nurse? A. "Anyone saying this to you must have a problem with his or her own drinking" B. "Although their intentions are good, they have no right to judge another persons drinking" C. "Do you think they may be jealous that you can drink more than they can? D. "Perhaps they have noticed that your drinking creates consequences for you"
D. "Perhaps they have noticed that your drinking creates consequences for you" Rationale: It indicates one of the areas of the CAGE questionnaire that deals with expressed concern from others about client's drinking. It is inappropriate to assume that those speaking to the client have drinking problems. This statement could support the clients projection of the drinking problem. Stating others have no right to judge the client labels those individuals as judgemental and diminishes their concern for the client. Asking about others' motives of jealousy is nontherapeutic and judgemental
What would be an appropriate nursing concern for a client with a history of substance abuse who is admitted to the hospital for chest pain? A. Altered family processes due to alcoholism B. Inability to manage therapeutic regimen C. Potential for injury D. Difficulties with decision making
D. Difficulties with decision making Rationale: Difficulty in decision-making, which can lead to pronounced anxiety and possible chest pain, can occur when there is uncertainty about a course of action or difficulty choosing among competing actions that involve risk, loss, or challenge to personal life values. Altered family processes due to alcoholism may apply, but it is more appropriate for the family than for the individual. Inability to manage the therapeutic regimen implies that the client has already made a commitment to recovery. Since the client probably abuses or is dependent on alcohol, a potential for injury may be present, but there is no specific information in the question to suggest this.
A nurse is conducting an in-service program on risk factors for victims of domestic violence. The nurse should include which information about risk factors during the session? Select all that apply. A. A high school dropout is at higher risk than a high school graduate B. Individuals of lower economic status are at higher risk than those of higher economic status C. Gay and lesbian individuals are not at risk D. Domestic violence cuts across all socioeconomic lines E. Domestic violence cuts across all educational levels
D. Domestic violence cuts across all socioeconomic lines E. Domestic violence cuts across all educational levels Rationale: Domestic violence occurs in all socioeconomic sectors. Domestic violence cuts across all educational levels. A high school dropout is not at higher risk than a high school graduate. Individuals of lower socioeconomic status are not at higher risk than those of higher economic status. Domestic violence can occur in gay and lesbian couples.
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings would alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypotension, coarse hand tremors, lethargy D. Hypertension, changes in level of consciousness, hallucinations
D. Hypertension, changes in level of consciousness, hallucinations Rationale: Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level ofd consciousness, agitation, fever, and delusions
A 15-year-old student visits the school nurse's office asking about date rape and pregnancy. She confides that her boyfriend forced her to have sex against her will. What would be the most appropriate initial intervention by the nurse? A. Administer a pregnancy test B. Teach safe sex practices C. Teach methods of birth control D. Identify the student's immediate concerns and feelings
D. Identify the student's immediate concerns and feelings Rationale: The client has been sexually assaulted, and the nurse needs to respond to the client's immediate concerns. Since the student describes occurrences that often lead to a situational crisis response, it is most important for the nurse to allow the student to ventilate feelings at the beginning of the interview. The nurse should listen patiently and supportively, understanding that compulsive retelling helps the victim gradually become desensitized to the sexual assault. Pregnancy testing can be done after the client has ventilated feelings about the sexual assault. Teaching is a secondary intervention that can be begun after the client has ventilated feelings about the sexual assault and other care has been administered.
The 12 steps of AA teach that A. Acceptance of being an alcoholic will prevent urges to drink. B. A Higher Power will protect individuals if they feel like drinking. C. Once a person has learned to be sober, he or she can graduate and leave AA. D. Once a person is sober, he or she remains at risk to drink.
D. Once a person is sober, he or she remains at risk to drink.
A nurse is evaluating a family in which an 18-month-old son has been abused by both parents. During the initial nursing interview, the parents stated that they spank the toddler because he "cries and cries and never tells us what is wrong." The parents are adolescents who are still in high school. The nurse determines that what parental outcome would indicate progress? A. Less use of spanking for discipline B. Joint attendance at parenting classes C. Holding unreasonable expectations for their child D. Recognizing crying as an age-appropriate way to communicate
D. Recognizing crying as an age-appropriate way to communicate Rationale: The parents need to learn that 18-month-old children cry as a means of communication. The word "less" in "less use of spanking" makes it incorrect, since the child should not be spanked for crying. Attendance at parenting classes does not indicate behavior change. Having unreasonably high expectations for children is a continued risk factor for abuse. Understanding normal growth and development will help the parents have more reasonable expectations of the child.
