Sexual Abuse & Trauma
Which of the following is a primary goal of nursing care when assessing a patient who has experienced intimate partner violence (IPV)?
A) To provide immediate medical intervention for injuries.
B) To ensure the patient has a safe environment and resources for support.
C) To encourage the patient to leave their abuser immediately.
D) To make a formal report to law enforcement immediately.
B) To ensure the patient has a safe environment and resources for support.
Which of the following stress management techniques would be most appropriate for a client experiencing chronic stress and insomnia?
A) Encouraging the client to engage in high-intensity exercise late in the evening
B) Recommending mindfulness meditation to promote relaxation
C) Suggesting that the client watch television to distract from their stress
D) Advising the client to take naps during the day to make up for lost sleep
Answer: B) Recommending mindfulness meditation to promote relaxation
Rationale:
Mindfulness meditation has been shown to be effective in reducing stress, promoting relaxation, and improving sleep quality. It helps reduce the physiological effects of stress, making it a suitable option for clients experiencing chronic stress and insomnia.
A nurse is caring for a patient who underwent hip replacement surgery 2 days ago. The patient is experiencing mild pain, but their primary concern is being able to walk again. The patient’s goal is to walk 50 feet within a week.
Question:
Which of the following goals is the best example of a SMART goal for this patient?
A) The patient will be able to walk 50 feet independently in one week.
B) The patient will achieve pain relief by the end of the week.
C) The patient will demonstrate an improvement in mobility within two days.
D) The patient will receive adequate pain medication every four hours.
Answer:
A) The patient will be able to walk 50 feet independently in one week.
Rationale:
This goal is SMART because it is Specific (walking 50 feet independently), Measurable (50 feet), Achievable (with physical therapy), Relevant (related to mobility post-surgery), and Time-limited (within one week). The other options are either vague, not patient-centered, or do not include a measurable outcome.
You are caring for a 55-year-old patient who has just undergone abdominal surgery. The patient rates their pain as 7/10 and reports feeling discomfort when moving or taking deep breaths. The patient has been receiving oral pain medication every 4 hours, but they still express dissatisfaction with their pain relief.
Question:
What is the most appropriate action to take next?
A) Administer the prescribed pain medication and inform the physician about the patient's dissatisfaction with pain control.
B) Reassess the patient's pain level after 30 minutes to evaluate the effectiveness of the current pain medication.
C) Encourage the patient to use relaxation techniques and deep breathing exercises instead of administering more medication.
D) Ask the patient to rate their pain again, but do not administer any more medication until the next dose is due.
Answer:
A) Administer the prescribed pain medication and inform the physician about the patient's dissatisfaction with pain control.
Rationale:
Pain management should be adjusted based on the patient's response to treatment. If the patient is still reporting significant pain (7/10), additional pain management interventions may be needed. Informing the physician about the patient's dissatisfaction allows for possible adjustments to the treatment plan, such as a different analgesic or dosage. Option B may delay pain relief, and C and D do not address the immediate need for pain management.
A 55-year-old woman with Meniere’s disease is experiencing an acute episode of vertigo and tinnitus. She feels nauseous and unsteady, with a sense of fullness in her right ear.
Which of the following nursing interventions is most appropriate to implement during an acute episode of Meniere’s disease?
A) "Encourage the patient to stay in an upright position to prevent further dizziness."
B) "Administer prescribed antiemetics to relieve nausea and prevent vomiting."
C) "Provide a quiet, darkened environment to minimize stimuli and prevent triggering another attack."
D) "Help the patient to stand and walk around to reduce the sensation of fullness in the ear."
C) "Provide a quiet, darkened environment to minimize stimuli and prevent triggering another attack."
Rationale:
During an acute Meniere’s disease episode, the patient experiences vertigo, tinnitus, nausea, and a feeling of ear fullness. The priority intervention is to provide a calm, quiet environment to reduce stimuli and prevent exacerbating symptoms. Anti-nausea medications may be given as prescribed, and the patient should be encouraged to lie down to ensure safety during dizziness. The focus should be on minimizing sensory overload and promoting rest.
A nurse is caring for a patient who was recently in a motor vehicle accident. The nurse notes that the patient’s vital signs are stable, but the patient is displaying signs of agitation, irritability, and flashbacks. What is the most appropriate nursing action?
A) Focus on addressing the physical injuries first.
B) Encourage the patient to speak in detail about the accident.
C) Assess the patient for signs of post-traumatic stress disorder (PTSD).
D) Provide medication to control the patient’s agitation.
C) Assess the patient for signs of post-traumatic stress disorder (PTSD).
A nurse is applying Roy’s Adaptation Model to assess a client experiencing chronic stress. The nurse is particularly concerned with the client’s ability to meet physiological needs. Which of the following nursing actions is most appropriate?
A) Assess the client’s coping mechanisms and defense strategies
B) Address the client’s emotional distress through counseling
C) Ensure that the client has adequate nutrition, hydration, and sleep
D) Focus on the client’s social relationships and role functions
Answer: C) Ensure that the client has adequate nutrition, hydration, and sleep
Rationale:
In Roy’s Adaptation Model, physiological needs are essential for adaptation. Ensuring the client’s basic needs, such as nutrition, hydration, and rest, are met is a priority when stress affects the body’s physical functioning.
You are a nurse in the ICU caring for four patients. The following is a list of patient conditions. Which patient should you prioritize?
A) Patient A: A 56-year-old male with a history of COPD and recent exacerbation who is on oxygen therapy but has decreased breath sounds and an oxygen saturation of 88%.
B) Patient B: A 72-year-old female with a fractured leg who is requesting pain medication and has stable vital signs.
C) Patient C: A 40-year-old male who just underwent elective knee surgery and is complaining of mild pain but is otherwise stable.
D) Patient D: A 90-year-old female who has a new diagnosis of diabetes and needs assistance with insulin education.
A) Patient A
Rationale:
Patient A, with decreased breath sounds and an oxygen saturation of 88%, is at risk for respiratory failure and requires immediate attention to ensure adequate oxygenation and prevent further deterioration. Airway, breathing, and circulation (ABCs) are always the highest priority in clinical care. The other patients, while needing attention, do not present an immediate life-threatening situation.
A 60-year-old patient with osteoarthritis is prescribed an NSAID for pain management. The patient is also taking a blood thinner due to a history of atrial fibrillation. The nurse is about to administer the NSAID.
Question:
What is the most important consideration before administering the NSAID to this patient?
A) Ensure the patient has not eaten in the last 2 hours.
B) Check the patient's most recent creatinine levels.
C) Confirm that the patient has no history of gastrointestinal ulcers.
D) Assess the patient’s blood pressure to ensure it is within normal limits
C) Confirm that the patient has no history of gastrointestinal ulcers.
Rationale:
NSAIDs can irritate the gastrointestinal tract and may increase the risk of bleeding, especially in patients with a history of ulcers. Given that this patient is also on a blood thinner, it is crucial to ensure there is no history of gastrointestinal ulcers or bleeding risk. Option B (creatinine levels) would be important if the patient had renal issues, but it is not the most immediate concern in this scenario. Option A is less relevant, as the NSAID can be taken with food. Monitoring blood pressure (Option D) is important but not as directly related to NSAID administration.
A nurse is conducting an eye exam for a patient who reports blurred vision and difficulty seeing objects at a distance. The nurse checks the patient’s pupils and notes that they are slow to respond to light.
Which of the following assessments should the nurse prioritize to evaluate the patient’s visual acuity?
A) Inspecting the sclera for redness or yellowing.
B) Assessing the ability of the pupil to constrict when exposed to light.
C) Checking for the presence of arcus senilis.
D) Measuring the visual acuity using a Snellen chart.
D) Measuring the visual acuity using a Snellen chart.
Rationale:
Measuring visual acuity with a Snellen chart is the most direct way to assess the patient’s ability to see at different distances and can help identify conditions such as myopia or hyperopia. Inspecting the sclera and assessing the pupils for light response are important, but visual acuity testing is the priority when the patient reports blurred vision.
When caring for a patient who has experienced sexual assault, what is the priority nursing action during the forensic exam?
A) Providing emotional support and ensuring the patient’s safety.
B) Documenting the patient's statement of the assault.
C) Collecting forensic evidence, including DNA samples.
D) Ensuring the patient receives immediate pain management.
A) Providing emotional support and ensuring the patient’s safety.
Which of the following is an appropriate assessment question when evaluating a client’s ability to cope with stress?
A) "Do you feel that your stress will eventually go away?"
B) "How have you been able to manage your stress so far?"
C) "Why don’t you try to avoid thinking about your problems?"
D) "Have you experienced stress at work or home?"
Answer: B) "How have you been able to manage your stress so far?"
Rationale:
This question encourages the client to reflect on and identify existing coping mechanisms. It also helps the nurse assess the effectiveness of the client's coping strategies. Open-ended questions about past coping efforts are more useful than yes/no questions.
A patient presents with severe abdominal pain and has a history of gallstones. Upon assessment, the patient rates the pain as 8/10, is grimacing with movement, and is clutching their right abdomen.
Question:
Which of the following is the most appropriate nursing diagnosis for this patient?
A) Impaired physical mobility related to abdominal pain as evidenced by inability to walk.
B) Alteration in comfort related to pain as evidenced by pain level of 8/10 and grimacing.
C) Risk for infection related to abdominal surgery as evidenced by fever and elevated WBC.
D) Imbalanced nutrition: less than body requirements related to nausea as evidenced by vomiting.
Answer:
B) Alteration in comfort related to pain as evidenced by pain level of 8/10 and grimacing.
Rationale:
The most appropriate nursing diagnosis is alteration in comfort related to pain, as evidenced by the patient’s reported pain level and physical signs (grimacing and clutching abdomen). This focuses on the patient’s current comfort needs and addresses the cause of the discomfort (pain) specifically. The other options do not accurately address the patient’s presenting problem.
A patient with chronic cancer pain has a PCA (patient-controlled analgesia) pump set for continuous morphine infusion and on-demand doses. The patient reports breakthrough pain that is not adequately relieved by the PCA, and their pain is rated at 9/10.
Question:
What is the most appropriate nursing action?
A) Encourage the patient to use the PCA more frequently, as it is likely they are not utilizing it to its full potential.
B) Administer a bolus dose of morphine via the PCA and assess the patient's response in 15 minutes.
C) Contact the physician to discuss increasing the continuous infusion dose of morphine.
D) Assess for any non-pharmacologic interventions the patient can try, such as repositioning or relaxation techniques.
C) Contact the physician to discuss increasing the continuous infusion dose of morphine.
Rationale:
For patients experiencing breakthrough pain despite using a PCA, it is appropriate to reassess the pain management plan. The nurse should contact the physician to consider increasing the PCA dose or adding additional medications (such as a breakthrough dose of morphine or a different analgesic). Options A and B assume that the PCA is being used correctly and may delay necessary adjustments. Option D is supportive, but it does not address the need for pharmacologic adjustment for severe pain.
Patient: A 68-year-old male patient has had cataract surgery on his left eye. The patient is being discharged, and the nurse is providing postoperative education.
Which of the following should the nurse include in the patient’s discharge instructions?
A) "You should sleep on your stomach to promote faster healing."
B) "Avoid heavy lifting, bending forward, and sneezing for the first few weeks to prevent increased intraocular pressure."
C) "You should discontinue all prescribed eye drops as soon as you begin to feel better."
D) "Wear your prescribed eye patch for 72 hours after surgery to prevent any pressure on the operated eye."
B) "Avoid heavy lifting, bending forward, and sneezing for the first few weeks to prevent increased intraocular pressure."
Rationale:
Postoperative care for cataract surgery involves preventing increased intraocular pressure (IOP) that could lead to complications such as hemorrhage or damage to sutures. Patients should avoid activities that might strain the eye, such as bending forward or heavy lifting. An eye patch is typically worn for 24 hours, and patients should continue to use prescribed eye drops as directed to promote healing and prevent infection.
Which of the following is an appropriate nursing action when caring for a patient who has experienced a traumatic event and is exhibiting signs of acute stress disorder (ASD)?
A) Encourage the patient to suppress their emotions until they can "get over it."
B) Reassure the patient that their feelings are normal and provide support.
C) Focus solely on addressing the physical injuries the patient has sustained.
D) Advise the patient to avoid discussing the trauma to prevent re-traumatization.
B) Reassure the patient that their feelings are normal and provide support.
Which of the following is an example of a sociocultural stressor?
A) Family conflict
B) Chronic illness
C) Financial hardship
D) Racism or discrimination
Answer: D) Racism or discrimination
Rationale:
Sociocultural stressors are stressors that arise from social and cultural contexts, such as racism, discrimination, and cultural or language barriers. These can cause significant emotional and psychological distress.
ou are caring for a patient who is post-operative following abdominal surgery. The patient is at risk for infection and has not yet been started on antibiotics. The physician is rounding in an hour.
Question:
Which of the following actions should you take immediately in the implementation phase of the nursing process?
A) Administer the ordered prophylactic antibiotic if it is due.
B) Discuss the patient's condition with the physician and ask if antibiotics are appropriate.
C) Wait until the physician rounds before addressing the patient's needs.
D) Offer the patient pain medication and assist with ambulation.
A) Administer the ordered prophylactic antibiotic if it is due.
Rationale:
If the physician has prescribed a prophylactic antibiotic and it is due, it should be administered as part of infection prevention. This is an essential intervention to reduce the risk of infection after surgery. Discussing the patient's condition with the physician or waiting until rounds delays necessary care, and while pain management and ambulation are important, the immediate priority is preventing infection.
You are caring for a 75-year-old patient with severe arthritis pain. The patient has a history of hypertension and renal insufficiency. They are prescribed acetaminophen for pain relief.
Question:
Which of the following is the most important intervention to ensure safe administration of acetaminophen?
A) Administer acetaminophen every 6 hours regardless of the patient's pain level.
B) Limit acetaminophen use to no more than 3,000 mg per day.
C) Advise the patient to take acetaminophen with food to prevent gastrointestinal upset.
D) Reassess the patient's pain every 4 hours to determine if acetaminophen is effective.
B) Limit acetaminophen use to no more than 3,000 mg per day.
Rationale:
In older adults, especially those with renal insufficiency, it is crucial to avoid exceeding the recommended maximum daily dose of acetaminophen (3,000 mg). Exceeding this limit increases the risk of liver toxicity. While taking acetaminophen with food (Option C) can help reduce gastrointestinal upset, it is not the primary concern here. Reassessing pain (Option D) and administering every 6 hours (Option A) are important but do not address the specific risk of acetaminophen overdose.
A 60-year-old man has been diagnosed with open-angle glaucoma. He is prescribed timolol eye drops (a beta-blocker) to reduce intraocular pressure.
Which of the following teaching points should the nurse emphasize regarding the patient’s use of timolol eye drops?
A) "This medication should be applied directly into the pupil for the best effect."
B) "If you experience increased heart rate or palpitations, discontinue use and contact your doctor immediately."
C) "Timolol can cause eye redness, but this is a normal side effect and does not require medical attention."
D) "Use the eye drops as needed when you notice a change in vision."
B) "If you experience increased heart rate or palpitations, discontinue use and contact your doctor immediately."
Rationale:
Timolol is a non-selective beta-blocker that decreases intraocular pressure. It can have systemic effects, including bradycardia and hypotension, and patients should be advised to report any signs of systemic absorption such as increased heart rate or palpitations. The medication should be used as prescribed, and patients should press on the inner canthus to prevent systemic absorption.
A nurse is caring for a 9-year-old child who has been suspected of being a victim of physical abuse. The child presents with multiple bruises in different stages of healing. Which of the following actions should the nurse take? (Select all that apply.)
A) Ask the child directly about the cause of the bruises to obtain a clear history.
B) Take photographs of the injuries with the child's consent.
C) Report suspected abuse to the appropriate authorities.
D) Reassure the child that they will be safe once they go home.
E) Document the injuries and any discrepancies between the injuries and the child's explanation.
B) Take photographs of the injuries with the child's consent.,
C) Report suspected abuse to the appropriate authorities.,
E) Document the injuries and any discrepancies between the injuries and the child's explanation.
Rachael, a 32-year-old nurse manager in a medical intensive care unit, has been feeling overwhelmed due to increasing client and staff dissatisfaction. In addition, her husband’s recent hospitalizations and inability to work have added emotional stress. She reports difficulty concentrating, sleep disturbances, and an increase in alcohol consumption to cope.
As Rachael’s nurse, which of the following is the most appropriate initial intervention to help her manage stress?
A) Suggest that Rachael take a week off work to rest and recover.
B) Discuss her feelings and stressors, then offer relaxation techniques like deep breathing.
C) Encourage Rachael to take on more responsibilities at work to distract herself from personal issues.
D) Advise Rachael to ignore her stress and continue her routine without making any changes.
Answer:
B) Discuss her feelings and stressors, then offer relaxation techniques like deep breathing.
Rationale:
It’s important to first address Rachael’s emotional and psychological distress by discussing her stressors in a supportive way. Offering coping techniques like deep breathing helps activate the parasympathetic nervous system, promoting relaxation and reducing stress. Ignoring the stress or recommending excessive work can exacerbate the problem.
You are caring for a patient who was admitted with acute pain from a surgical wound. The goal was for the patient’s pain to be below 4/10 by the end of your shift. After assessing the patient, the pain level is reported as 5/10, and the patient states that they are still uncomfortable despite receiving pain medication.
Question:
How should you evaluate the goal?
A) The goal was met because the pain level is lower than it was at the start.
B) The goal was partially met because the pain level has decreased but is still higher than the target.
C) The goal was not met because the patient is still experiencing pain.
D) The goal was met because the patient is still able to ambulate.
B) The goal was partially met because the pain level has decreased but is still higher than the target.
Rationale:
The goal of pain relief to a level of 4/10 or less was not fully met, but the pain was reduced from its previous level. Therefore, the goal was partially met, and further interventions are needed to address the remaining pain. The other responses fail to recognize the need for further action to meet the full goal.
A patient who was recently prescribed oxycodone for post-operative pain asks you about the potential side effects. The patient is concerned about becoming addicted to the medication.
Question:
What is the most important information to include in your response?
A) "You will only become addicted to the medication if you take it for an extended period."
B) "Opioids are very addictive, but if you take them exactly as prescribed, the risk of addiction is low."
C) "Addiction to opioids is not a concern because you are using them for legitimate pain management."
D) "If you experience any side effects, contact your doctor to discuss a medication change."
B) "Opioids are very addictive, but if you take them exactly as prescribed, the risk of addiction is low."
Rationale:
Opioid medications, including oxycodone, have a potential for addiction, especially if used incorrectly. It is essential to educate the patient about taking the medication only as prescribed and to discuss the risks of misuse. The other options either downplay the risks of addiction or do not provide sufficient guidance on safe medication use.
Patient: A 72-year-old woman presents with difficulty reading, distorted vision, and a dark spot in the center of her vision. She is diagnosed with non-exudative (dry) macular degeneration.
Which of the following is the most important point the nurse should emphasize in educating the patient?
A) "There is no cure for macular degeneration, but lifestyle changes and early treatment can help slow progression."
B) "You should expect that your vision will return to normal with appropriate treatment."
C) "Macular degeneration is caused by high blood pressure, so your doctor will likely treat that condition first."
D) "Photocoagulation surgery is the most effective treatment, and it should be done immediately to prevent further vision loss."
A) "There is no cure for macular degeneration, but lifestyle changes and early treatment can help slow progression."
Rationale:
Age-related macular degeneration (AMD) has no cure, but certain treatments, including antioxidant vitamins, can help slow the progression of the disease. Lifestyle changes such as smoking cessation and dietary changes may also help. Patients with the wet form of AMD may benefit from treatments like photocoagulation, but the dry form does not have such immediate surgical interventions. The focus is on slowing the disease's progression and managing vision loss.