問題一覧
1
- As a professional nurse, one of your roles is an advocate for the patient's rights. The following questions refer to these statements.
You were invited by a women's organization to be the resource speaker on "Violence against women and children". Women and their children are protected against violence under Republic Act No.
Republic Act No. 9262
2
One of the violent acts is sexual violence. Which of the following does NOT constitute sexual violence?
Economic abuse
3
What should be the nurse' s MAIN concern when a case of abuse,
maltreatment, or neglect is suspected in a patient?
Reporting the incidence to proper authorities
4
What is the MOST common clinical manifestation of child neglect?
Malnutrition and dehydration
5
What should be the focus of care for patients who are suspected to be abused, maltreated, or neglected?
Referral to legal authorities
6
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
What behavior will Nurse Nat King Cole observe as characterized by Natalie?
Failure to develop interpersonal skills
7
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
At her age, Natalie is in what stage of social development?
Initiative vs Guilt
8
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
Murse Nat King Cole recognizes which as a common behavioral sign of autism?
Indifference to being hugged or held
9
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
The best nursing intervention that Nurse Nat King Cole can use to provide a trusting relationship with Natalie in to
provide a structured environment
10
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
Which pharmacologic treatment is appropriate for Natalie's temper tantrum, aggressiveness, self-injury and stereotype behavior?
Haloperidol (Haldol)
11
Prince, a 9-year-old first grader child, has always been the subject of her mother's prompting and care because of having attention deficit hyperactivity disorder (ADHD). He always tests his mom's rule in preparing for school. Although this has gone on for five months now, Prince still has to be reminded in getting dressed completely and dilly dally eating his breakfast. He still plays with his toys and interferes with her sister in playing blocks. The mother is so anxious in reminding Prince that his school bus will be arriving in 10 minutes every day.
ADHD is NOT characterized by which of the following?
Mental retardation
12
Prince, a 9-year-old first grader child, has always been the subject of her mother's prompting and care because of having attention deficit hyperactivity disorder (ADHD). He always tests his mom's rule in preparing for school. Although this has gone on for five months now, Prince still has to be reminded in getting dressed completely and dilly dally eating his breakfast. He still plays with his toys and interferes with her sister in playing blocks. The mother is so anxious in reminding Prince that his school bus will be arriving in 10 minutes every day.
Which would the nurse expect to see as symptoms in a child with ADHD?
Interrupts others and can't wait to take turns
13
Prince is taking pemoline (Cylert) for
ADHD. The nurse must be aware of which of the following side effects?
Elevated liver function test results
14
An effective nursing intervention for the impulsive and aggressive behavior that accompany conduct disorder is
consistent limit setting
15
Nursing diagnosis commonly used when working with Prince who has ADHD
Risk of injury
16
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
What are the effects of drinking coffee two to three cups a day on the central nervous system?
Feeling motivated and energized, less fatigued
17
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
Which of the following reinforces a person to continue drinking coffee?
Feeling of well-being
18
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
Britney was given Luminal 60mg/day per oren. Thie drug is a/an
long-acting sedative
19
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
While doing your assessment Britney complained of nausea. Which of the following would be your priority nursing action?
Offering Britney some ice chips.
20
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
You have observed that Britney keeps on pacing in the room, restless, and stutters when you speak to her. You would assess Britney was manifesting which of the following anxiety responses?
Behavioral
21
Luther, a 50-year-old house painter, came in with chief complaints of slurred speach, blurring of vision, and hallucinations. Upon evaluation of his case, it reveled that Luther had volatile substance intoxication.
Based on the situation, the predisposing factor in Luther's case is his:
occupation.
22
Luther, a 50-year-old house painter, came in with chief complaints of slurred speach, blurring of vision, and hallucinations. Upon evaluation of his case, it reveled that Luther had volatile substance intoxication.
Volatile substance abuse is considered the most dangerous among the abused psychoactive substance because of the risk of
irreversible damage to the bone marrow, brain, liver, kidney
23
Luther, a 50-year-old house painter, came in with chief complaints of slurred speach, blurring of vision, and hallucinations. Upon evaluation of his case, it reveled that Luther had volatile substance intoxication.
The nurse heard Luther saying, "My mother visited me last night and reminded me to take care of myself." This is a manifestation of
auditory hallucination
24
Substance abuse affects not only the user but also the other members of the family of the user. Which of the following is the MOST APPROPRIATE nursing diagnosis in the care of Luther?
Dysfunctional family processes
25
Severe intoxication to volatile aubstances may lead to unconsciousness or even death. The priority nursing intervention in caring for such patient is monitoring the
neurological functions
26
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
During the Frank's assessment, which is the most appropriate question to ask?
Ask Frank about the amount of drug he has taken and how long he has been using.
27
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
Upon data collection, Frank has failed three times in his Math class after being substance dependent for three years. What is the most appropriate nursing diagnosis for him?
Ineffective individual coping
28
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
Frank has been using meperidine and codeine for personal consumption. Which does the nurse understand as the physiologic effect of these drugs?
Relieves pain by increased threshold
29
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
Which assessment by the nurse would cause a concern for meperidine overdose?.
Pinpoint pupils
30
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
The nurse prepares which drug to reverse all signs of toxicity?
Naloxone (Narcan)
31
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
When assessing Justin, the nurse notes polyneuropathy and skin changes. The nurse knows these are results of deficiency of:
Vitamin B
32
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
The staff suspected alcohol withdrawal. Which of the following cluster of symptoms should be noted as withdrawal symptoms?
Agitated, confused, frightened, combative and can't be calmed down
33
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
Prompt care of alcoholism is essential. The nurse's vigilance starts when:
At most eight hours from the time the patient last drank alcohol
34
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
The nursing staff ensures Justin's safety during treatment. While giving nursing care, Justin verbalized fearing the presence of a snake around him. Which of the following approaches is LEAST therapeutic?
"This is a rolled-up belt to restrain you temporarily. It can't hurt you."
35
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
The health team is discussing a plan of treatment of Justin. After providing him with the necessary information about his illness, the MOST important aspect to consider in his rehabilitation is:
commitment and motivation for treatment
36
You are a staff nurse in a Rehabilitation Center for Substance Abuse and you are tasked to help out patients recover from their bad habits.
You admitted an intoxicated patient for alcohol withdrawal. Which of the following interventions should you implement to help the client become sober?
Provide a quiet room to sleep in.
37
You are a staff nurse in a Rehabilitation Center for Substance Abuse and you are tasked to help out patients recover from their bad habits.
While obtaining the history of a patient with several cases of driving under the influence of alcohol, you asked about the amount of alcohol the patient consumes daily. He answered, "I just have a few drinks with the guys after work." Which of the following would be your most therapeutic response?
"You say you have a few drinks, but you have multiple arrests."
38
You are a staff nurse in a Rehabilitation Center for Substance Abuse and you are tasked to help out patients recover from their bad habits.
Which data provides the best information on the patient's physiologic response and effectiveness of the medication presaribed for alcohol withdrawal?
Vital signs
39
One of your patients is manifesting signs and symptoms of alcohol withdrawal such as: tremors, diaphoresis, and hyperactivity.
Blood pressure is 190/92 mmig and pulse rate of 92 bpm. Which should you expeat to be ordered?
Lorazepam
40
A patient discharged from an alcohol rehabilitation program was on clonazepam (Klonopin) 0.5mg, three times a day. Several months later, he reported having insomnia, shakiness, sweating, and one seizure. Which of the following questions should you asked first? Ask if he
Has stopped taking the Klonopin suddenly
41
Health care professionals have increased rates of substance use problem’s, particularly Involving opioids, stimulants and sedatives.
The nurse has provided an in-service program on impaired professionals. She knows that teaching has been effective when staff identify which as the highest risk for subatance abuse among professionals?
Most nurses are exposed to various substances and believe they are not at risk of developing the disease.
42
A nurse comes to work intoxicated but says he is not. The nurse is displaying:
denial.
43
The nurse says she drinks vodka every morning to calm her nerves and stop her tremors. The nurse realizes the client is at risk for
physical dependence.
44
Which behaviors would indicate stimulant intoxication?
Hyperactivity & talkativeness
45
Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which nursing assessment is essential before giving a dose of this medication?
Assessing the blood pressure
46
Nurses inform patients taking antipsychotic medications about the types of side affects that may occur. She encourages patients to report instead of discontinuing the medications.
Followings are related to patient teachings.
When taken antianxiety drugs like Benzodiazepines, which APPROPRIATE health teaching should the nurse emphasize?
Patient should not drink alcohol because it potentiates its effect.
47
When taking anticonvulsant drugs like lithium, which APPROPRIATE HEALTH TEACHINGS should the nurse emphasize?
Time of last dose must be accurate so that blood level monitoring be accurate.
48
Which of the following does NOT signify extrapyramidal symptoms (EPS) Haldol?
Increased libido
49
The patient often appears restless, anxious, agitated with rigid posture and lack of spontaneous gestures. Which of the following describes this patient with intense need to move about?
Akathisia
50
When taking SSRI (selective serotonin reuptake inhibitors), Which APPROPRIATE health teaching should nurse amphasize?
Patient should take the drug first thing in the morning.
51
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
Which of the following statements indicates that the client needs further teaching?
"I'm so glad I can have pizza as long as I don't order pepperoni."
52
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
Patient's health teaching for Lanotrigine (Lamictal) should include which of the following?
Report any rashes to your doctor immediately.
53
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
Which of the ff health teaching concern for the nurses as discharged plan for suicidal patient who haad been taking tricyclic antidepressants drugs for 2 weeks and now ready to go home?
The nurse will evaluate the risk for suicide by overdose of tricyclic antidepressants
54
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
A patient in to take regularly Lithium after discharged. The MOST important information to impart to the patient and his family in that the patient should
Have an adequate intake of sodium
55
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
The patient with diagnonis of Schizophrenia who has been taking Clozapine will inform the patient family that the positive effect of this drug in
Patient's energy level and involvement in activities goes up.
56
During the Morning Circle when patients gather together, the nurse noticed that Whitney has been restless, was not focused and left the group early.
After the group interaction, the nurse approach Whitney and said,
"Whitney, I noticed that you were restless during the Morning Circle and you left the group three times." The nurse communicated with the patient by:
Verbalizing an observation
57
Whitney stated, "I get nervous if I am in a group."
The nurse responded, "You get,nervous if you are in a group?" What makes the nurse therapeutic?
It allowed the patient to validate that the nurse understood
58
Whitney says, "I feel scared." The nurse responds, "When did you begin to feel this way?" The nurse's response:
Helps to discuss the event in sequence of actions, thoughts and feelings”
59
Duzing the nurse-patient interaction,
Whitney verbalized to the nurse that she is like her mother. Whitney is demonstrating:
Transference
60
This attitude allows the nurse to perceive the patient with objectivity:
Empathy
61
Neil asked the nurse to have an "out on pass" privilege for the weekend but his request was not granted by the nurse. He remarked, "I thought you really liked me." A therapeutic response of the nurse would be:
"Your behavior did not meet criteria for out on pass privilege."
62
The dynamics of behavior underlying manipulative behavior is a behavior of:
struggle for security and control.
63
Victoria, an elderly patient idealizes some nurses as "terrific," "the best," or "so understanding," but refers to others as
"mean," "incompetent" or "indifferent." This behavior can be understood by the staff as:
avoiding taking responsibility for her own behavior and underlying feelings.
64
A patient with delirium touches the nurse inappropriately. The response of the nurse would- be:
remove patient's hand while saying, "I'm the nurse and this is a hospital."
65
The staff nurses have differing emotional reactions to the use of limit setting. Some staff view it as unprofessionally punitive and uncaring. The most appropriate approach to address this nursing concern is through:
nursing conference
66
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
You have observed that Aretha is manifesting “splitting".
This characteristic of BPD is BEST defined as:
Viewing people and objects as parts, either good or bad
67
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
When assessing a patient with BPD which of the following information would you focus on?
Disruption in some aspects of his/her life
68
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
Aretha rovealed she has a tendency to manipulate others. What would be the MOST APPROPRIATE short-term goal for her? For Aretha to
Acknowledge her own behavior
69
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
Patients with BPD manifest transient psychotic symptoms. What is the drug of choice to treat these symptoms?
Antipsychotics
70
Arotha has a history of alcohol abuse so she was started on Antabuse. When of the following is a COMMON side effect of this drug?
Hypertension
71
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
Chaka, is demonstrating behavioral signs of:
Schizotypal personality
72
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
The nursing diagnosis that requires priority：
Impaired nutrition
73
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
Chaka responds to the nurse's question.
"I don't need help. Leave me alone. I am just fine." She is coping by utilizing:
Denial
74
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
Groups of people like Chaka, necessitate need for:
Social action
75
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
The nurse assesses for psychosis by observing any symptons of:
Delusions and hallucination
76
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
While caring for this client, the family notices that loud noises cause a serious anxiety response. Which of the following explanations by you would help the family understand the client’s response?
After a trauma, the client cannot respond to stimuli in an appropriate manner
77
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following instructions should you include about relationships for this client with post-traumatic stress disorder?
Assess the client's discomfort when talking about feelings to family members
78
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following nursing interventions would best help this client and her family handle interpersonal conflict at home? Have the family:
Discuss how to change dysfunctional family patterns
79
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following nursing actions would be more appropriate when speaking with this client about the trauma she experienced?
Listen attentively
80
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following nursing actions would you include in the plan of care for this client who keeps saying that the trauma she experienced was just a case of bad luck?
Encourage client to verbalize the experience
81
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Which statement should Nurse Paula say to Janet?
"Would you like to relate to me what happened?"
82
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
In providing nursing care for Janet during her acute stress reaction to
Rape trauma, Nurse Paula may apply, which of the following?
Crisis intervention techniques
83
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Janet's physical assessment is complete and physical evidence has been colleated. After three days, Nurse Paula noted Janet to be withdrawn, confused and at times physically immobile.
How should Nurse Paula interpret these behaviors?
Normal reactions to a devastating ovent
84
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Emergency care to be given for a rape victim are as follows:
I. If victim calls the hospital, tell her not to take a bath, wash or
change cloths, just go directly to the hospital
II. Provide privacy and be judgmental
III. Stay with the victim, focus on physical safety and emotional security
IV. Assist on pelvic examination to collect evidences as semen stains.
I,III,IV
85
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Nurse Paula wanted to become a patients advocate for rape victims.
Which of the following responsibilities should she note?
Postpone the physical examination until the patient is calm.
86
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Which of the following is the precipitating factor fo Diana’s feeling of wanting to die?
The death of Dionne
87
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Diana's feeling of joining Dionne in heaven is a manifestation of:
Suicidal ideation
88
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Diana states "I will hang myself". This is a manifestation of:
Suicidal threat
89
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Which of the following is the best predictor of adolescents attempting
suicide?
Joyful mood
90
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Diana states "I wish I were dead. I cannot stand anymore not having Dionne around." Your most appropriate nursing action would be:
Explore Diana’s feeling
91
Nurse Fatima who is on duty in a psychiatric unit is assigned to care for patients at risk for suicide.
Nurse Fatima should pursue assessment of suicide risk for individuals who display tendencies to be?
Hostile, impulsive, or depressed
92
Nurse Fatima who is on duty in a psychiatric unit is assigned to care for patients at risk for suicide.
On admission, the nursing diagnosis for Gringo, who is depressed and suicidal is, "Risk for suicide". An appropriate outcome for this diagnosis at discharge from the hospital is, "The patient will
Be able to problem-solve effectively
93
Nurse Fatima who is on duty in a psychiatric unit is assigned to care for patients at risk for suicide.
Which of the following statements would best represent Nurse Fatima's attempt to assess a patient's current ability to organize and enact a suicide wish?
"What plan do you have for committing suicide?"
94
A male suicidal patient is found by Nurse Fatima as he tries to hang himself in the bathroom. What nursing intervention would
address the patient's need for safety while maintaining his self-esteem?
Advise him to use the bathroom only with staff supervision
95
In evaluation the effectiveness of the care provided for a self-destructive pationt, the best approach is to?
Involve patient in the process of evaluation
96
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
Angela says "My dead mother ordered me to kill my two children before the devil could get them". What behavior is being manifested by Angela?
Auditory hallucination
97
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
You asked Angela to touch a 25-centavo coin and a one-peso coin. You have observed that Angela was having difficulty differentiating one coin from the other. This is a manifestation of
Astereognosis
98
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
You have observad that Angela is manifesting persistent hallucinations. What is the MOST EFFECTIVE therapy in treating patient with a condition like that of Angela's?
Anti-psychotic drugs
99
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
Which is the GOAL of nursing intervention for a patient who is hallucinating?
To help the patient to have an increased awareness that the symptoms she is experiencing is not real
100
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
What communication technique would be most Effective
to achieve the nursing goal for patient with hallucination?
Facilitative communication
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Disorders Related to Alterations in Cognition and Perception
47問 • 1年前Anxiety and Alterations in Mood
Anxiety and Alterations in Mood
Kyla Angelique Son · 86問 · 1年前Anxiety and Alterations in Mood
Anxiety and Alterations in Mood
86問 • 1年前Alterations in Behavior
Alterations in Behavior
Kyla Angelique Son · 43問 · 1年前Alterations in Behavior
Alterations in Behavior
43問 • 1年前Neuromusculoskeletal System
Neuromusculoskeletal System
Kyla Angelique Son · 65問 · 1年前Neuromusculoskeletal System
Neuromusculoskeletal System
65問 • 1年前Communicable dx
Communicable dx
Kyla Angelique Son · 27問 · 1年前Communicable dx
Communicable dx
27問 • 1年前NP2
NP2
Kyla Angelique Son · 46問 · 1年前NP2
NP2
46問 • 1年前NP4
NP4
Kyla Angelique Son · 58問 · 1年前NP4
NP4
58問 • 1年前PALMR
PALMR
Kyla Angelique Son · 48問 · 1年前PALMR
PALMR
48問 • 1年前Sexual andGender Identity Disorders
Sexual andGender Identity Disorders
Kyla Angelique Son · 12問 · 1年前Sexual andGender Identity Disorders
Sexual andGender Identity Disorders
12問 • 1年前問題一覧
1
- As a professional nurse, one of your roles is an advocate for the patient's rights. The following questions refer to these statements.
You were invited by a women's organization to be the resource speaker on "Violence against women and children". Women and their children are protected against violence under Republic Act No.
Republic Act No. 9262
2
One of the violent acts is sexual violence. Which of the following does NOT constitute sexual violence?
Economic abuse
3
What should be the nurse' s MAIN concern when a case of abuse,
maltreatment, or neglect is suspected in a patient?
Reporting the incidence to proper authorities
4
What is the MOST common clinical manifestation of child neglect?
Malnutrition and dehydration
5
What should be the focus of care for patients who are suspected to be abused, maltreated, or neglected?
Referral to legal authorities
6
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
What behavior will Nurse Nat King Cole observe as characterized by Natalie?
Failure to develop interpersonal skills
7
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
At her age, Natalie is in what stage of social development?
Initiative vs Guilt
8
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
Murse Nat King Cole recognizes which as a common behavioral sign of autism?
Indifference to being hugged or held
9
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
The best nursing intervention that Nurse Nat King Cole can use to provide a trusting relationship with Natalie in to
provide a structured environment
10
Natalie, 4 years old, was diagnosed as autistic since she was a toddler.
Which pharmacologic treatment is appropriate for Natalie's temper tantrum, aggressiveness, self-injury and stereotype behavior?
Haloperidol (Haldol)
11
Prince, a 9-year-old first grader child, has always been the subject of her mother's prompting and care because of having attention deficit hyperactivity disorder (ADHD). He always tests his mom's rule in preparing for school. Although this has gone on for five months now, Prince still has to be reminded in getting dressed completely and dilly dally eating his breakfast. He still plays with his toys and interferes with her sister in playing blocks. The mother is so anxious in reminding Prince that his school bus will be arriving in 10 minutes every day.
ADHD is NOT characterized by which of the following?
Mental retardation
12
Prince, a 9-year-old first grader child, has always been the subject of her mother's prompting and care because of having attention deficit hyperactivity disorder (ADHD). He always tests his mom's rule in preparing for school. Although this has gone on for five months now, Prince still has to be reminded in getting dressed completely and dilly dally eating his breakfast. He still plays with his toys and interferes with her sister in playing blocks. The mother is so anxious in reminding Prince that his school bus will be arriving in 10 minutes every day.
Which would the nurse expect to see as symptoms in a child with ADHD?
Interrupts others and can't wait to take turns
13
Prince is taking pemoline (Cylert) for
ADHD. The nurse must be aware of which of the following side effects?
Elevated liver function test results
14
An effective nursing intervention for the impulsive and aggressive behavior that accompany conduct disorder is
consistent limit setting
15
Nursing diagnosis commonly used when working with Prince who has ADHD
Risk of injury
16
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
What are the effects of drinking coffee two to three cups a day on the central nervous system?
Feeling motivated and energized, less fatigued
17
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
Which of the following reinforces a person to continue drinking coffee?
Feeling of well-being
18
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
Britney was given Luminal 60mg/day per oren. Thie drug is a/an
long-acting sedative
19
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
While doing your assessment Britney complained of nausea. Which of the following would be your priority nursing action?
Offering Britney some ice chips.
20
Britney, a 28-year-old supervisor in a call center, consulted at the out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. Britney was diagnosed with Caffeine Discontinuation Syndrome (CDS)
You have observed that Britney keeps on pacing in the room, restless, and stutters when you speak to her. You would assess Britney was manifesting which of the following anxiety responses?
Behavioral
21
Luther, a 50-year-old house painter, came in with chief complaints of slurred speach, blurring of vision, and hallucinations. Upon evaluation of his case, it reveled that Luther had volatile substance intoxication.
Based on the situation, the predisposing factor in Luther's case is his:
occupation.
22
Luther, a 50-year-old house painter, came in with chief complaints of slurred speach, blurring of vision, and hallucinations. Upon evaluation of his case, it reveled that Luther had volatile substance intoxication.
Volatile substance abuse is considered the most dangerous among the abused psychoactive substance because of the risk of
irreversible damage to the bone marrow, brain, liver, kidney
23
Luther, a 50-year-old house painter, came in with chief complaints of slurred speach, blurring of vision, and hallucinations. Upon evaluation of his case, it reveled that Luther had volatile substance intoxication.
The nurse heard Luther saying, "My mother visited me last night and reminded me to take care of myself." This is a manifestation of
auditory hallucination
24
Substance abuse affects not only the user but also the other members of the family of the user. Which of the following is the MOST APPROPRIATE nursing diagnosis in the care of Luther?
Dysfunctional family processes
25
Severe intoxication to volatile aubstances may lead to unconsciousness or even death. The priority nursing intervention in caring for such patient is monitoring the
neurological functions
26
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
During the Frank's assessment, which is the most appropriate question to ask?
Ask Frank about the amount of drug he has taken and how long he has been using.
27
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
Upon data collection, Frank has failed three times in his Math class after being substance dependent for three years. What is the most appropriate nursing diagnosis for him?
Ineffective individual coping
28
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
Frank has been using meperidine and codeine for personal consumption. Which does the nurse understand as the physiologic effect of these drugs?
Relieves pain by increased threshold
29
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
Which assessment by the nurse would cause a concern for meperidine overdose?.
Pinpoint pupils
30
Incidence of drug abuse has greatly increased over the years. As a response to this, you bacame a Drug Abuse Treatment and Rehabilitation Center Nurse and Frank, your patient, neads your help for he has been "using drugs".
The nurse prepares which drug to reverse all signs of toxicity?
Naloxone (Narcan)
31
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
When assessing Justin, the nurse notes polyneuropathy and skin changes. The nurse knows these are results of deficiency of:
Vitamin B
32
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
The staff suspected alcohol withdrawal. Which of the following cluster of symptoms should be noted as withdrawal symptoms?
Agitated, confused, frightened, combative and can't be calmed down
33
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
Prompt care of alcoholism is essential. The nurse's vigilance starts when:
At most eight hours from the time the patient last drank alcohol
34
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
The nursing staff ensures Justin's safety during treatment. While giving nursing care, Justin verbalized fearing the presence of a snake around him. Which of the following approaches is LEAST therapeutic?
"This is a rolled-up belt to restrain you temporarily. It can't hurt you."
35
Justin, a 42-year-old man, had undergone an exploratory laparotomy. His first postoperative assessment showed that he's somewhat anxious, agitated and not easily reassured or calmed. Staff suspected alcohol withdrawal.
The health team is discussing a plan of treatment of Justin. After providing him with the necessary information about his illness, the MOST important aspect to consider in his rehabilitation is:
commitment and motivation for treatment
36
You are a staff nurse in a Rehabilitation Center for Substance Abuse and you are tasked to help out patients recover from their bad habits.
You admitted an intoxicated patient for alcohol withdrawal. Which of the following interventions should you implement to help the client become sober?
Provide a quiet room to sleep in.
37
You are a staff nurse in a Rehabilitation Center for Substance Abuse and you are tasked to help out patients recover from their bad habits.
While obtaining the history of a patient with several cases of driving under the influence of alcohol, you asked about the amount of alcohol the patient consumes daily. He answered, "I just have a few drinks with the guys after work." Which of the following would be your most therapeutic response?
"You say you have a few drinks, but you have multiple arrests."
38
You are a staff nurse in a Rehabilitation Center for Substance Abuse and you are tasked to help out patients recover from their bad habits.
Which data provides the best information on the patient's physiologic response and effectiveness of the medication presaribed for alcohol withdrawal?
Vital signs
39
One of your patients is manifesting signs and symptoms of alcohol withdrawal such as: tremors, diaphoresis, and hyperactivity.
Blood pressure is 190/92 mmig and pulse rate of 92 bpm. Which should you expeat to be ordered?
Lorazepam
40
A patient discharged from an alcohol rehabilitation program was on clonazepam (Klonopin) 0.5mg, three times a day. Several months later, he reported having insomnia, shakiness, sweating, and one seizure. Which of the following questions should you asked first? Ask if he
Has stopped taking the Klonopin suddenly
41
Health care professionals have increased rates of substance use problem’s, particularly Involving opioids, stimulants and sedatives.
The nurse has provided an in-service program on impaired professionals. She knows that teaching has been effective when staff identify which as the highest risk for subatance abuse among professionals?
Most nurses are exposed to various substances and believe they are not at risk of developing the disease.
42
A nurse comes to work intoxicated but says he is not. The nurse is displaying:
denial.
43
The nurse says she drinks vodka every morning to calm her nerves and stop her tremors. The nurse realizes the client is at risk for
physical dependence.
44
Which behaviors would indicate stimulant intoxication?
Hyperactivity & talkativeness
45
Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which nursing assessment is essential before giving a dose of this medication?
Assessing the blood pressure
46
Nurses inform patients taking antipsychotic medications about the types of side affects that may occur. She encourages patients to report instead of discontinuing the medications.
Followings are related to patient teachings.
When taken antianxiety drugs like Benzodiazepines, which APPROPRIATE health teaching should the nurse emphasize?
Patient should not drink alcohol because it potentiates its effect.
47
When taking anticonvulsant drugs like lithium, which APPROPRIATE HEALTH TEACHINGS should the nurse emphasize?
Time of last dose must be accurate so that blood level monitoring be accurate.
48
Which of the following does NOT signify extrapyramidal symptoms (EPS) Haldol?
Increased libido
49
The patient often appears restless, anxious, agitated with rigid posture and lack of spontaneous gestures. Which of the following describes this patient with intense need to move about?
Akathisia
50
When taking SSRI (selective serotonin reuptake inhibitors), Which APPROPRIATE health teaching should nurse amphasize?
Patient should take the drug first thing in the morning.
51
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
Which of the following statements indicates that the client needs further teaching?
"I'm so glad I can have pizza as long as I don't order pepperoni."
52
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
Patient's health teaching for Lanotrigine (Lamictal) should include which of the following?
Report any rashes to your doctor immediately.
53
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
Which of the ff health teaching concern for the nurses as discharged plan for suicidal patient who haad been taking tricyclic antidepressants drugs for 2 weeks and now ready to go home?
The nurse will evaluate the risk for suicide by overdose of tricyclic antidepressants
54
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
A patient in to take regularly Lithium after discharged. The MOST important information to impart to the patient and his family in that the patient should
Have an adequate intake of sodium
55
The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid.
The patient with diagnonis of Schizophrenia who has been taking Clozapine will inform the patient family that the positive effect of this drug in
Patient's energy level and involvement in activities goes up.
56
During the Morning Circle when patients gather together, the nurse noticed that Whitney has been restless, was not focused and left the group early.
After the group interaction, the nurse approach Whitney and said,
"Whitney, I noticed that you were restless during the Morning Circle and you left the group three times." The nurse communicated with the patient by:
Verbalizing an observation
57
Whitney stated, "I get nervous if I am in a group."
The nurse responded, "You get,nervous if you are in a group?" What makes the nurse therapeutic?
It allowed the patient to validate that the nurse understood
58
Whitney says, "I feel scared." The nurse responds, "When did you begin to feel this way?" The nurse's response:
Helps to discuss the event in sequence of actions, thoughts and feelings”
59
Duzing the nurse-patient interaction,
Whitney verbalized to the nurse that she is like her mother. Whitney is demonstrating:
Transference
60
This attitude allows the nurse to perceive the patient with objectivity:
Empathy
61
Neil asked the nurse to have an "out on pass" privilege for the weekend but his request was not granted by the nurse. He remarked, "I thought you really liked me." A therapeutic response of the nurse would be:
"Your behavior did not meet criteria for out on pass privilege."
62
The dynamics of behavior underlying manipulative behavior is a behavior of:
struggle for security and control.
63
Victoria, an elderly patient idealizes some nurses as "terrific," "the best," or "so understanding," but refers to others as
"mean," "incompetent" or "indifferent." This behavior can be understood by the staff as:
avoiding taking responsibility for her own behavior and underlying feelings.
64
A patient with delirium touches the nurse inappropriately. The response of the nurse would- be:
remove patient's hand while saying, "I'm the nurse and this is a hospital."
65
The staff nurses have differing emotional reactions to the use of limit setting. Some staff view it as unprofessionally punitive and uncaring. The most appropriate approach to address this nursing concern is through:
nursing conference
66
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
You have observed that Aretha is manifesting “splitting".
This characteristic of BPD is BEST defined as:
Viewing people and objects as parts, either good or bad
67
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
When assessing a patient with BPD which of the following information would you focus on?
Disruption in some aspects of his/her life
68
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
Aretha rovealed she has a tendency to manipulate others. What would be the MOST APPROPRIATE short-term goal for her? For Aretha to
Acknowledge her own behavior
69
You are a staff nurse in the Psychiatric Unit of a Private hospital, Aretha, a 20-year-old stage actress, was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that sho has also the tendency to manipulate people and feels unhappy most of the time. Aretha was diagnosed to be suffering from borderline personality disorder (BPD)
Patients with BPD manifest transient psychotic symptoms. What is the drug of choice to treat these symptoms?
Antipsychotics
70
Arotha has a history of alcohol abuse so she was started on Antabuse. When of the following is a COMMON side effect of this drug?
Hypertension
71
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
Chaka, is demonstrating behavioral signs of:
Schizotypal personality
72
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
The nursing diagnosis that requires priority：
Impaired nutrition
73
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
Chaka responds to the nurse's question.
"I don't need help. Leave me alone. I am just fine." She is coping by utilizing:
Denial
74
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
Groups of people like Chaka, necessitate need for:
Social action
75
Chaka is a 50-year-old homeless female who was brought in the emergency room of the hospital after experiencing a hypoglyce mic episode in the waiting shed of a bus station. She is unkampt,
eccentric, grimaces inappropriately, wearing three layers of clothing and mismatched shoes.
The nurse assesses for psychosis by observing any symptons of:
Delusions and hallucination
76
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
While caring for this client, the family notices that loud noises cause a serious anxiety response. Which of the following explanations by you would help the family understand the client’s response?
After a trauma, the client cannot respond to stimuli in an appropriate manner
77
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following instructions should you include about relationships for this client with post-traumatic stress disorder?
Assess the client's discomfort when talking about feelings to family members
78
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following nursing interventions would best help this client and her family handle interpersonal conflict at home? Have the family:
Discuss how to change dysfunctional family patterns
79
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following nursing actions would be more appropriate when speaking with this client about the trauma she experienced?
Listen attentively
80
You are a community health nurso assisting a family in the care of their daughter suffering from post-traumatic stress disorder.
Which of the following nursing actions would you include in the plan of care for this client who keeps saying that the trauma she experienced was just a case of bad luck?
Encourage client to verbalize the experience
81
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Which statement should Nurse Paula say to Janet?
"Would you like to relate to me what happened?"
82
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
In providing nursing care for Janet during her acute stress reaction to
Rape trauma, Nurse Paula may apply, which of the following?
Crisis intervention techniques
83
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Janet's physical assessment is complete and physical evidence has been colleated. After three days, Nurse Paula noted Janet to be withdrawn, confused and at times physically immobile.
How should Nurse Paula interpret these behaviors?
Normal reactions to a devastating ovent
84
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Emergency care to be given for a rape victim are as follows:
I. If victim calls the hospital, tell her not to take a bath, wash or
change cloths, just go directly to the hospital
II. Provide privacy and be judgmental
III. Stay with the victim, focus on physical safety and emotional security
IV. Assist on pelvic examination to collect evidences as semen stains.
I,III,IV
85
Janet, a 24-year-old evening cashier working in Mini Stop,
was sexually abused by a motorcycle driver while she was on her way home from work one evening. She was brought to the ER with bruises all over her body. Janet was crying uncontrollably and appears to bo anxious.
Nurse Paula wanted to become a patients advocate for rape victims.
Which of the following responsibilities should she note?
Postpone the physical examination until the patient is calm.
86
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Which of the following is the precipitating factor fo Diana’s feeling of wanting to die?
The death of Dionne
87
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Diana's feeling of joining Dionne in heaven is a manifestation of:
Suicidal ideation
88
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Diana states "I will hang myself". This is a manifestation of:
Suicidal threat
89
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Which of the following is the best predictor of adolescents attempting
suicide?
Joyful mood
90
Diana, a 10-yaar-old grade four student in a private school
has just lost her best friend , Dionne, who died of Ewing's sarcoma (Bone CA). Her mother brought her to the Emergency Room who reported that Diana has been gloomy and often expresses feeling of
"Joining Dionne in heaven."
Diana states "I wish I were dead. I cannot stand anymore not having Dionne around." Your most appropriate nursing action would be:
Explore Diana’s feeling
91
Nurse Fatima who is on duty in a psychiatric unit is assigned to care for patients at risk for suicide.
Nurse Fatima should pursue assessment of suicide risk for individuals who display tendencies to be?
Hostile, impulsive, or depressed
92
Nurse Fatima who is on duty in a psychiatric unit is assigned to care for patients at risk for suicide.
On admission, the nursing diagnosis for Gringo, who is depressed and suicidal is, "Risk for suicide". An appropriate outcome for this diagnosis at discharge from the hospital is, "The patient will
Be able to problem-solve effectively
93
Nurse Fatima who is on duty in a psychiatric unit is assigned to care for patients at risk for suicide.
Which of the following statements would best represent Nurse Fatima's attempt to assess a patient's current ability to organize and enact a suicide wish?
"What plan do you have for committing suicide?"
94
A male suicidal patient is found by Nurse Fatima as he tries to hang himself in the bathroom. What nursing intervention would
address the patient's need for safety while maintaining his self-esteem?
Advise him to use the bathroom only with staff supervision
95
In evaluation the effectiveness of the care provided for a self-destructive pationt, the best approach is to?
Involve patient in the process of evaluation
96
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
Angela says "My dead mother ordered me to kill my two children before the devil could get them". What behavior is being manifested by Angela?
Auditory hallucination
97
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
You asked Angela to touch a 25-centavo coin and a one-peso coin. You have observed that Angela was having difficulty differentiating one coin from the other. This is a manifestation of
Astereognosis
98
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
You have observad that Angela is manifesting persistent hallucinations. What is the MOST EFFECTIVE therapy in treating patient with a condition like that of Angela's?
Anti-psychotic drugs
99
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
Which is the GOAL of nursing intervention for a patient who is hallucinating?
To help the patient to have an increased awareness that the symptoms she is experiencing is not real
100
Angela, a 40-year-old, single mother of two preschool children,
aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children.
What communication technique would be most Effective
to achieve the nursing goal for patient with hallucination?
Facilitative communication