A patient tells the nurse, "My doctor prescribed Paxil (paroxetine) for my depression. I assume I'll have side effects like I had when I was taking Tofranil (imipramine)." The nurse's reply should be based on the knowledge that paroxetine is a:
Rationale:
Paroxetine is a selective serotonin reuptake inhibitor (SSRI). SSRIs, like paroxetine, primarily increase serotonin levels in the brain, leading to mood improvement, and they typically produce a different side effect profile than tricyclic antidepressants like Tofranil.
A: Selective norepinephrine reuptake inhibitor. Paroxetine does not primarily target norepinephrine; instead, it focuses on enhancing serotonin levels, distinguishing it from norepinephrine reuptake inhibitors.
B: Tricyclic antidepressant. Unlike tricyclics, which have a broader range of effects and potential side effects, paroxetine is an SSRI with a more specific action on serotonin.
C: MAO inhibitor. Paroxetine does not function as a monoamine oxidase inhibitor; it selectively inhibits serotonin reuptake, which is fundamentally different from the mechanism of MAO inhibitors.
A psychosis arising from an advanced stage of syphilis, in which the disease attacks brain cells, is called
Rationale:
A psychosis arising from an advanced stage of syphilis, in which the disease attacks brain cells, is called general paresis.
General paresis is directly linked to the neuropsychiatric complications of syphilis, where the infection leads to significant brain damage, resulting in psychotic symptoms. This condition exemplifies the profound effects of untreated syphilis on mental health and neurological function, highlighting its severity and the need for timely intervention.
A: Korsakoff's syndrome manifests primarily from thiamine deficiency, often associated with chronic alcoholism, leading to memory disturbances, not related to syphilis or its psychological effects.
B: Delirium tremens occurs due to acute alcohol withdrawal, presenting with severe confusion and hallucinations, distinct from the long-term neurodegenerative impact seen in advanced syphilis cases.
C: Schizotypical psychosis involves a chronic mental disorder characterized by eccentric behavior and cognitive distortions, unrelated to the neurological degeneration caused by syphilis, thus lacking direct connection.
An adolescent claims to have been physically abused by a parent. The adolescent's other parent angrily tells the nurse, 'It's ridiculous for our child to accuse my spouse, who's a prominent doctor and is respected by the community.' Which of these nursing communications would be most effective for the parent?
Rationale:
A: You believe that abuse does not exist in well-respected, professional families? The statement challenges the parent’s perception by emphasizing that abuse can occur in any family, regardless of status, prompting reflection on their beliefs about abuse and encouraging openness to the adolescent’s claims.
B: Your spouse seems to have a very stressful, demanding practice. This statement implies that stress may lead to inappropriate behavior, but it diverts attention from the child's allegations, potentially dismissing their experience.
C: I know that it is difficult to believe what your child is saying about your spouse, but abuse has occurred. While acknowledging the parent's struggle, this option lacks a direct challenge to their denial, limiting engagement in the discussion.
D: I know your spouse from working in the emergency room. This approach focuses on the spouse’s kindness, which could minimize the seriousness of the accusations, failing to address the child's claims assertively.
A rape victim asks a nurse, 'How do I know whether this attack was my fault?' Which response by the nurse is therapeutic?
Rationale:
Support the victim to separate issues of vulnerability from blame.
This response is therapeutic as it helps the victim understand that the attack is not a reflection of their worth or choices, thereby promoting healing and self-empowerment in a vulnerable moment.
B: Make decisions for the victim because of the temporary confusion. This approach undermines the victim's autonomy, potentially exacerbating feelings of helplessness rather than fostering a supportive environment for recovery.
C: Reassure the victim that the outcome of the situation will be positive. Offering false reassurance might invalidate the victim's feelings and experiences, hindering their ability to process the trauma effectively.
D: None of the above. This option ignores the importance of providing a supportive and validating response, which is essential in addressing the victim's concerns and promoting emotional healing.
What should the nurse do when a patient with anorexia nervosa expresses a fear of gaining weight?
Rationale:
Providing information about the importance of weight gain for health is essential for addressing the patient's fear of gaining weight. Educating the patient fosters understanding and encourages a collaborative approach towards recovery, emphasizing the benefits of achieving a healthy weight.
A: Minimize the patient's fears to avoid anxiety. Dismissing fears may invalidate the patient’s feelings and hinder open communication, essential for building trust and facilitating effective treatment.
C: Encourage weight loss to help the patient feel more in control. Promoting weight loss contradicts the therapeutic goal and may exacerbate the patient's condition, leading to further health complications.
D: Agree with the patient's concerns and avoid discussing the topic. Avoidance prevents necessary dialogue and education, which are crucial for managing anorexia nervosa and supporting the patient's recovery journey.
A nurse is performing an assessment for a 59-year-old man with a long history of hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment?
Rationale:
Sexual dysfunction may result from use of prescription medications for management of hypertension. Assessing the patient's medication can illuminate potential side effects and guide appropriate interventions, improving overall patient care and quality of life.
B: Such questions provide insight into medication adherence but do not directly address the specific link between hypertension treatments and sexual function, which is crucial for comprehensive assessment.
C: Transitioning to sexual practices might be easier, yet this approach overlooks the primary concern of medication-related sexual dysfunction that must be directly addressed for effective management.
D: While sexual dysfunction can indeed induce stress, it does not directly relate to the rationale for inquiring about prescribed medications and their effects, which is the assessment's primary focus.
During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (SHT2) excess will suggest that the client receive:
Rationale:
Olanzapine (Zyprexa) is suggested for the client due to its efficacy in addressing negative symptoms associated with schizophrenia, such as apathy and blunted affect, which relate to serotonin dysregulation.
A: Haloperidol (Haldol) Primarily targets positive symptoms of schizophrenia and may not effectively address the persistent negative symptoms like apathy and avolition exhibited by the client.
B: Chlorpromazine (Thorazine) While it has antipsychotic properties, it is less effective in managing the specific negative symptoms related to serotonin excess seen in this case.
D: Phenelzine (NardiI) As a monoamine oxidase inhibitor, it is more suitable for depression rather than treating the negative symptoms of schizophrenia linked to serotonin dysregulation.
To provide nursing care to abused children and their families, the nurse must first:
Rationale:
To examine personal feelings regarding the trauma of child abuse and neglect is essential for nurses to provide empathetic and effective care. Self-reflection enables a clearer understanding of biases and emotional responses, facilitating better communication and support for affected families.
A: Complete a comprehensive physical and mental assessment Focusing solely on assessments neglects the emotional and psychological aspects that are critical in addressing trauma in abused children and their families.
B: Recommend removal of the children from the family Suggesting removal prematurely can exacerbate family trauma and disrupt the therapeutic process, highlighting the need for careful consideration of emotional dynamics first.
C: Refer each case to the appropriate social worker for follow-up Immediate referral may overlook the nurse's crucial role in addressing their own feelings, which is vital for effective collaboration and support.
A primigravida patient at 34 weeks gestation presents with a history of not having felt fetal movements for 24 hours. Which one of the following statements is most appropriate?
Rationale:
C: She should have urgent antenatal cardiotocography (CTG).
Immediate CTG assessment is vital in this scenario to monitor fetal heart activity and determine the well-being of the fetus, especially after a significant decrease in perceived fetal movements.
A: She probably has an intra-uterine fetal death.
This statement lacks confirmation; fetal death cannot be assumed without appropriate monitoring and evaluation, such as CTG, which provides essential information about fetal status.
B: You should immediately arrange transfer to labour ward for early induction labour, providing the baby is still alive.
Inducing labor prematurely without assessing fetal well-being first through CTG can pose unnecessary risks and complications, making this approach inappropriate before confirming fetal viability.
D: She should have an ultrasound scan.
While an ultrasound can provide information, prioritizing CTG is crucial as it offers immediate insight into fetal heart activity, which is essential in this urgent situation.
What is the primary concern when a patient with bulimia nervosa engages in frequent purging?
Rationale:
Electrolyte imbalances and dehydration. Frequent purging in bulimia nervosa leads to significant loss of electrolytes, which can disrupt heart rhythms and muscle function, while dehydration further complicates the patient’s overall health status, risking severe medical consequences.
B: Increased risk of obesity and metabolic syndrome. Frequent purging typically leads to weight fluctuations rather than obesity, as patients often maintain a low average weight, countering the risk of metabolic syndrome.
C: Improvement in body image and self-esteem. Engaging in purging does not foster positive body image or self-esteem; rather, it often exacerbates feelings of shame and guilt associated with eating behavior.
D: Decreased risk of gastrointestinal complications. Regular purging actually heightens the likelihood of gastrointestinal issues, including esophageal tears and severe digestive problems, contradicting any notion of decreased risk.
A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse's first action should be to:
Rationale:
A: Take the client's vital signs. Vital signs are critical to assess the client's immediate physical health status, identify any life-threatening conditions, and evaluate the potential impact of their altered mental state.
B: Restrain the client to prevent injury. Restraining a client may escalate agitation and confusion, further complicating their condition, rather than addressing the immediate need for a thorough assessment of their health.
C: Obtain a pm order for a psychotropic medication. Administering medication without understanding the client’s current physiological state could lead to adverse reactions, especially when vital signs have not been evaluated first.
D: Ask the client for information about his medications. The client’s disorientation and confusion might hinder reliable communication, making it impractical to gather medication information before assessing their vital signs and overall condition.
A nurse is caring for a patient with bulimia nervosa who is experiencing frequent purging. What is a priority assessment?
Rationale:
Monitor electrolyte levels and cardiac function. Frequent purging in bulimia nervosa can lead to severe electrolyte imbalances and cardiac complications, making it essential to prioritize these assessments for patient safety and effective management.
B: Observe for signs of dehydration and low blood pressure. While dehydration is a concern, monitoring electrolytes directly addresses the immediate risks associated with purging that could severely impact cardiac health.
C: Assess for any compulsive exercise behaviors. Although compulsive exercise can be a symptom of bulimia, it does not have the immediate life-threatening implications that electrolyte and cardiac monitoring presents in this context.
D: Monitor for changes in eating patterns and food preferences. Changes in eating habits are relevant but not as urgent as assessing electrolyte levels and cardiac functioning in a patient actively purging.
A patient's medical record documents sexual masochism. This patient derives sexual pleasure
Rationale:
Sexual masochism involves deriving sexual pleasure from experiences of humiliation or pain, often through submission to a partner. Therefore, this patient specifically finds pleasure when sexually humiliated by a partner, aligning with the definition of sexual masochism.
A: from inanimate objects. This option describes fetishism rather than masochism, which specifically involves interactions with partners to derive pleasure through humiliation or pain.
B: by inflicting pain on a partner. This choice pertains to sadism, where pleasure is derived from causing pain, contrasting with masochism, which focuses on receiving pain or humiliation.
D: from touching a nonconsenting person. This option implies non-consensual behavior, which does not align with the consensual nature often present in sexual masochism, where both parties typically agree to the dynamics.
A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:
Rationale:
A: Gain 1 to 2 pounds. Achieving a weight gain of 1 to 2 pounds within one week indicates progress in addressing the nursing diagnosis of Imbalanced nutrition, promoting overall recovery in patients with anorexia nervosa. This outcome signifies an improvement in nutritional intake and a positive response to the treatment plan.
B: Exercise 1 hour daily. Daily exercise is counterproductive in anorexia nervosa treatment, as it can exacerbate nutritional deficits and hinder weight restoration efforts, contrary to the desired improvement in nutritional status.
C: Take a laxative every 3 days. Laxative use contradicts the goal of increasing nutritional intake, as it can lead to further weight loss and disrupt the patient's efforts to achieve a healthier body weight.
D: Weigh self accurately using balanced scales. While self-weighing can be informative, it does not directly address nutritional intake or promote weight gain, which are essential outcomes for patients with anorexia nervosa.
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
Rationale:
Anticholinergic side effects are likely when a patient takes fluphenazine (Prolixin). This antipsychotic medication frequently leads to symptoms such as dry mouth, blurred vision, and constipation due to its anticholinergic properties, which inhibit neurotransmitter action in the nervous system.
A: Lithium (Lithobid) This mood stabilizer primarily affects neurotransmitter levels without significant anticholinergic activity, making related side effects unlikely in typical therapeutic use.
B: Buspirone (BuSpar) As an anxiolytic, buspirone does not exhibit anticholinergic properties, focusing instead on serotonin and dopamine receptor modulation, thus minimizing such side effects.
C: Risperidone (Risperdal) While risperidone can cause some side effects, its profile is not significantly associated with anticholinergic symptoms compared to medications like fluphenazine, which is known for these effects.
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _____, and the nurse should _____.
Rationale:
A dystonic reaction; administer PRN IM benztropine (Cogentin). This patient exhibits signs of dystonia, characterized by the fixed, abnormal posture of the head and jaw. Dystonic reactions are acute, often occurring after antipsychotic administration, and prompt treatment with anticholinergic agents like benztropine is necessary to alleviate symptoms and reduce anxiety.
B: Tardive dyskinesia; this condition develops after prolonged antipsychotic use and typically features involuntary movements, not the acute muscular rigidity and anxiety displayed by the patient.
C: Waxy flexibility; this term refers to a catatonic state where limbs can be manipulated and remain in place, which does not match the patient's tense and anxious demeanor.
D: Akathisia; characterized by restlessness and an urgent need to move, it does not account for the fixed posture and severe anxiety experienced by the patient in this scenario.
A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
Rationale:
B: Assessing the client for physical problems is the initial priority. Given the patient's prolonged mutism and motionlessness, it is crucial to rule out any underlying medical issues that may be contributing to his stupor and catatonic state before addressing psychological interventions.
A: Orienting the client to the unit fails to address potential physical health concerns, which may be critical in this situation. Prioritizing safety and health must come first.
C: Establishing a nonthreatening relationship is important but secondary. The immediate need is to ensure the client is not suffering from any acute medical conditions that require attention.
D: Reinforcing reality with the client is not suitable as the first step. The focus should be on assessing physical health, as the client's current condition may stem from medical issues.
When a patient with paranoid schizophrenia has a recurrence of positive symptoms after stopping his antipsychotic medication because of its postural hypotension (orthostasis) side effect, he is readmitted to the mental health unit. What measure should the nurse suggest to help the patient address this side effect?
Rationale:
D: Wear elastic support hose, drink adequate fluids, and change position slowly. This measure helps manage orthostasis by improving venous return, maintaining blood pressure, and reducing the risk of dizziness upon standing, which is crucial for patients experiencing postural hypotension.
A: Ask the doctor to prescribe an anticholinergic drug like trihexyphenidyl (Artane). This option does not address postural hypotension directly and is typically used for managing extrapyramidal symptoms rather than orthostatic issues.
B: Chew sugarless gum or use sugarless hard candy to moisten your mouth. While beneficial for dry mouth, this suggestion does not mitigate the significant concerns associated with postural hypotension.
C: Increase the amount of sleep you get, and try to take frequent rest breaks. Although helpful for overall well-being, this approach does not specifically target the management of orthostatic symptoms.
A patient with schizophrenia tells the nurse 'I don't know, it's just all the same. You never know. It comes, it goes, it blows away. Get it?' The best response for the nurse to make would be:
Rationale:
I am having difficulty understanding what you are saying.
This response acknowledges the patient's communication challenges without dismissing their feelings. It invites further dialogue while expressing the nurse's need for clarification, fostering a supportive therapeutic relationship essential in mental health care.
A: Nothing you are saying is clear; you are not making sense. This response may invalidate the patient’s experience, potentially increasing feelings of frustration and alienation instead of promoting open communication.
B: Yes, life can be like that sometimes, very confusing. This reply fails to address the patient’s specific concerns, leading to possible misunderstandings and a lack of clarity in communication.
C: Try to organize your thoughts and then tell me again. This suggestion places the burden of clarity on the patient rather than fostering a supportive environment that encourages open dialogue.
A patient tells the nurse, 'I can't go to any unit meetings because when I get in that room, everyone can hear my thoughts.' The nurse can correctly assess this symptom as:
Rationale:
C: thought broadcasting. This symptom indicates that the patient believes their thoughts are being transmitted to others, reflecting a profound disconnect from reality often associated with certain mental health conditions.
A: concrete thinking. This option involves an inability to understand abstract concepts, which does not align with the patient's expressed fear of others hearing their thoughts.
B: loose associations. This refers to a disorganized thought process where ideas are only loosely connected, not directly related to the patient’s concern about thought transmission.
D: auditory hallucinations. This entails perceiving sounds that are not present, while the patient’s statement specifically addresses the fear of their thoughts being audible to others, not hearing voices.
Which is the most appropriate initial goal for a nurse when attempting to overcome personal negative attitudes about a patient who has a history of returning to an abusive spouse?
Rationale:
Exploring own attitudes and values toward survivors of violence is the most appropriate initial goal for a nurse. This self-reflection allows the nurse to confront biases and foster empathy, which is essential in providing compassionate care to patients with complex histories.
B: Identifying the dysfunctional behaviors exhibited by the violent family focuses on external factors rather than the nurse's internal biases, which must be addressed first to improve patient interaction.
C: Concentrating on identifying any possible personal abusive relationships diverts attention from the nurse's current attitudes, which need examination before addressing patient situations effectively and empathetically.
D: Attending seminars on the psychological impact of being the victim of abuse enhances knowledge but does not directly address the nurse's own negative attitudes, which are crucial to overcome initially.
A woman who is a victim of severe emotional violence tells the nurse that her husband abuses her most often when he is intoxicated, just as his father had beaten him and his mother. The woman is aware of the location of a safe house and has considered leaving home with her two children, but she cites being brought up to believe 'you keep quiet and stay together, no matter what happens.' She states the husband is always apologetic and remorseful after an incident. The nurse responds, 'You cannot live like this; you have to defend yourself and your children.' Which statement most accurately describes the nurse's response?
Rationale:
You cannot live like this; you have to defend yourself and your children. The nurse’s response, while expressing concern, lacks professionalism as it does not provide appropriate support or solutions for the woman's situation, potentially undermining her autonomy and decision-making process.
A: It is an honest and direct response that will help build trust and rapport. Honesty does not equate to effective communication; the nurse's approach lacks sensitivity and fails to empower the woman.
B: It suggests that the nurse herself has been a victim of physical abuse. The nurse's personal history is irrelevant; the focus should remain on the woman’s needs and circumstances.
C: It is unprofessional, but it will likely help by motivating the patient. Motivation must be balanced with professionalism; the nurse's response risks alienating the patient instead of fostering a supportive environment.
A catatonic patient admitted in a stuporous condition begins to demonstrate increased motor activity. During his assessment, the psychiatrist raises the patient's arm above his head and releases it. The patient maintains the position his arm was placed in, immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. What symptom is demonstrated by this assessment technique?
Rationale:
B: Waxy flexibility. The patient's ability to maintain the arm in the elevated position for an extended period demonstrates waxy flexibility, a symptom commonly observed in catatonia, indicating a lack of voluntary movement control.
A: Echopraxia. This symptom involves the involuntary imitation of another person's actions, which does not relate to the patient's ability to hold a position without prompting.
C: Depersonalization. This condition refers to a feeling of disconnection from oneself, which does not apply to the patient's physical state or the observed motor behavior.
D: Thought withdrawal. This symptom entails a belief that thoughts are being taken away, unrelated to the physical manifestations of motor activity and immobility shown by the patient.
A woman has been severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, has no financial resources of her own, and has no job skills. Which would be the most important referral for the nurse to make?
Rationale:
D: Safe house or shelter. Given her situation of severe domestic violence, fear of returning home, and lack of support, a safe house or shelter provides immediate protection and essential resources for recovery.
A: Community food cupboard. While food assistance is valuable, it does not address her urgent need for safety and shelter from her abusive environment.
B: Vocational counseling. Although job skills are important for long-term independence, her immediate priority is securing a safe environment away from her abuser.
C: Law enforcement. Involving law enforcement may escalate the situation without addressing her immediate need for a safe space to escape the violence she faces.
A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
Rationale:
Monitoring for respiratory depression takes priority due to flunitrazepam's sedative effects, which can significantly impair breathing. Ensuring the victim's airway is clear and that they are breathing adequately is crucial for their immediate safety and recovery.
A: Coma Monitoring for coma is important; however, it is a later concern compared to the immediate risks of respiratory depression following flunitrazepam administration.
B: Seizures While seizures may occur, they are less likely than respiratory depression in cases of flunitrazepam overdose, making them a secondary concern in this scenario.
C: Hypotonia Hypotonia may be present but does not pose an immediate life-threatening risk compared to respiratory depression, which requires urgent attention and intervention.
The nurse is to perform a complete assessment of a client in her home, using the Mini-Mental State Examination as one component. When the nurse arrives, the client is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The client's husband says, 'Let's get on with this business.' The client is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be to:
Rationale:
The best action for the nurse to take would be to explain the importance of the testing process and make an appointment for another day when the environment can be better controlled.
This choice ensures that the assessment occurs in a suitable setting, free of distractions, which is crucial for obtaining accurate results from the Mini-Mental State Examination and understanding the client’s cognitive state.
A: Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room. This approach may still leave the client feeling uncomfortable and pressured during the assessment process.
C: Not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family. This option disregards the importance of direct assessment, which is essential for a comprehensive evaluation of the client's cognitive abilities.
D: Ask the husband to make an appointment to bring his wife to the clinic for testing. This option removes the immediate opportunity for assessment and places unnecessary barriers to obtaining timely care and evaluation.
A client has just been diagnosed with mild Alzheimer's disease. A family member asks what medications are used for treatment. The nurse knows that which of the following medications are the ones most used for mild to moderate Alzheimer's disease? (Select all that apply.)
Rationale:
Donepezil (Aricept) is one of the primary medications used for treating mild to moderate Alzheimer's disease. It works by increasing levels of acetylcholine, a neurotransmitter important for memory and cognition, thus alleviating symptoms associated with the condition.
A: Haloperidol (Haldol) Primarily used for psychiatric disorders, Haloperidol does not target the cognitive deficits characteristic of Alzheimer's and is not indicated for treating Alzheimer's symptoms.
C: Rivastigmine (Exelon) Although effective for Alzheimer's, it is not the only medication noted for mild cases; Donepezil is specifically highlighted as a preferred treatment.
D: Nonsteroidal antiinflammatory drugs These medications are primarily used for pain relief and inflammation, lacking efficacy in addressing the cognitive decline associated with Alzheimer's disease.
What is the priority intervention for a nurse caring for a patient with bulimia nervosa?
Rationale:
Assist the patient to identify triggers to binge eating.
Identifying triggers is crucial in treating bulimia nervosa as it helps the patient recognize patterns and emotional responses that lead to binge eating. This intervention fosters self-awareness, promotes coping strategies, and ultimately supports recovery by addressing the underlying issues contributing to the disorder.
B: Provide remedial consequences for weight loss. Implementing consequences may reinforce negative behaviors and lead to further emotional distress, thus contradicting the supportive therapeutic environment essential for recovery from bulimia nervosa.
C: Assess for signs of impulsive eating. While assessing impulsive eating is relevant, it does not directly address the core psychological factors and triggers that lead to binge eating episodes, which are critical to tackle first.
D: Explore needs for health teaching. Although health education is beneficial, it should follow the identification of triggers, as understanding these aspects is foundational before advancing to broader health teaching strategies in the treatment plan.
After being raped, a woman was told by her aunt, 'I'm not surprised that happened to you. You were asking for it.' A few days later, a friend told her, 'Well after all, he took you to dinner. He expected something in return.' The victim states, 'I can't believe that people can think that way.' The rape crisis nurse correctly hypothesizes that the client is:
Rationale:
Experiencing cognitive dissonance. The victim grapples with conflicting thoughts about the assault, as societal beliefs suggest blame shifts onto her. This inconsistency between her experience and others' perceptions creates psychological discomfort, highlighting her struggle to reconcile these opposing viewpoints.
B: In denial about the rape. The victim's expression of disbelief indicates she is processing the trauma rather than denying its occurrence, showing awareness of the event's reality.
C: Seeking validation from others. The victim's response reflects shock and confusion rather than a desire for affirmation, as she is confronting harmful societal attitudes instead of looking for support.
D: None of the above. The lack of relevant options underlines the importance of recognizing cognitive dissonance, making this choice irrelevant to the psychological conflict the victim is experiencing.
The head nurse on a unit that serves persons with cognitive impairment is concerned about her staff, many of whom seem to be becoming 'burned out' by their challenging work. Which response by the head nurse is most likely to minimize staff frustration and burnout on the unit? Select all that apply.
Rationale:
Educating staff regarding realistic expectations for this patient population provides them with a clearer understanding of challenges, reducing frustration and preventing feelings of inadequacy, which can significantly mitigate burnout.
B: Arrange for 12-hour shifts so that staff can have more days off per week. Extended shifts may lead to fatigue and decreased morale, counteracting potential benefits of increased time off.
C: Guide staff to use small, realistic goals as their measure of patient progress. While this may help, it does not directly address the root causes of staff frustration and burnout.
D: None of the above. This option dismisses all potential solutions, leaving staff without necessary support or strategies to cope with the challenges they face on the unit.
