During the initial care of rape victims the following are to be considered EXCEPT:

Touch the client to show acceptance and empathy

Accompany the client in the examination room.

Maintain a non-judgmental approach.

The nurse acts as a patient advocate when she does one of the following:

She postpones the physical assessment until the client is calm

She encourages the client to express her feeling regarding her experience.

She assesses the client for injuries.

She postpones the physical assessment until the client is calm

Explains to the client that her reactions are normal

Crisis intervention carried out to the client has this primary goal:

Help her return to her pre-rape level of function

Assist the client to express her feelings

Help her identify her resources

Support her adaptive coping skills

Help her return to her pre-rape level of function

Anxiety is caused by:

a subjectively perceived threat

It would be most helpful for the nurse to deal with a client with severe anxiety by:

Give specific instructions using speak in concise statements.

Ask the client to identify the cause of her anxiety.

Explain in detail the plan of care developed

Urge the client to focus on what the nurse is saying

Which of the following is included in the health teachings among clients receiving Valium?:

Take the medication after meals.

It is safe to stop it anytime after long term use.

Double up the dose if the client forgets her medication.

Psychiatric Nursing Pt. 9

1.

Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother. Rape is an example of which type of crisis:
- A.
  
  Situational
- B.
  
  Adventitious
- C.
  
  Developmental
- D.
  
  Internal
Correct Answer
B. Adventitious

Explanation
Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life

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2.

During the initial care of rape victims the following are to be considered EXCEPT:
- A.
  
  Assure privacy.
- B.
  
  Touch the client to show acceptance and empathy
- C.
  
  Accompany the client in the examination room.
- D.
  
  Maintain a non-judgmental approach.
Correct Answer
B. Touch the client to show acceptance and empathy

Explanation
Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed.

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3.

The nurse acts as a patient advocate when she does one of the following:
- A.
  
  She encourages the client to express her feeling regarding her experience.
- B.
  
  She assesses the client for injuries.
- C.
  
  She postpones the physical assessment until the client is calm
- D.
  
  Explains to the client that her reactions are normal
Correct Answer
C. She postpones the physical assessment until the client is calm

Explanation
She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher

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4.

Crisis intervention carried out to the client has this primary goal:
- A.
  
  Assist the client to express her feelings
- B.
  
  Help her identify her resources
- C.
  
  Support her adaptive coping skills
- D.
  
  Help her return to her pre-rape level of function
Correct Answer
D. Help her return to her pre-rape level of function

Explanation
Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal

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5.

Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from:
- A.
  
  Adjustment disorder
- B.
  
  Somatoform Disorder
- C.
  
  Generalized Anxiety Disorder
- D.
  
  Post traumatic disorder
Correct Answer
D. Post traumatic disorder

Explanation
Post traumatic disorder
Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months

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6.

Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying. The nurse assesses the level of anxiety as:
- A.
  
  Mild
- B.
  
  Moderate
- C.
  
  Severe
- D.
  
  Panic
Correct Answer
C. Severe

Explanation
Severe
The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization

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7.

Anxiety is caused by:
- A.
  
  An objective threat
- B.
  
  A subjectively perceived threat
- C.
  
  Hostility turned to the self
- D.
  
  Masked depression
Correct Answer
B. A subjectively perceived threat

Explanation
a subjectively perceived threat
Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression

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8.

It would be most helpful for the nurse to deal with a client with severe anxiety by:
- A.
  
  Give specific instructions using speak in concise statements.
- B.
  
  Ask the client to identify the cause of her anxiety.
- C.
  
  Explain in detail the plan of care developed
- D.
  
  Urge the client to focus on what the nurse is saying
Correct Answer
A. Give specific instructions using speak in concise statements.

Explanation
Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus.

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9.

Which of the following medications will likely be ordered for the client?”
- A.
  
  Prozac
- B.
  
  Vaium
- C.
  
  Risperdal
- D.
  
  Lithium
Correct Answer
B. Vaium

Explanation
Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic

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10.

Which of the following is included in the health teachings among clients receiving Valium?:
- A.
  
  Avoid foods rich in tyramine.
- B.
  
  Take the medication after meals.
- C.
  
  It is safe to stop it anytime after long term use.
- D.
  
  Double up the dose if the client forgets her medication.
Correct Answer
B. Take the medication after meals.

Explanation
Take the medication after meals.
Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.

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Psychiatric Nursing Pt. 9

Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother. Rape is an example of which type of crisis:

During the initial care of rape victims the following are to be considered EXCEPT:

The nurse acts as a patient advocate when she does one of the following:

Crisis intervention carried out to the client has this primary goal:

Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from:

Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying. The nurse assesses the level of anxiety as:

Anxiety is caused by:

It would be most helpful for the nurse to deal with a client with severe anxiety by:

Which of the following medications will likely be ordered for the client?”

Which of the following is included in the health teachings among clients receiving Valium?: