Answer Options:
a. Assign the child to a short time-out.
b. Administer an antipsychotic medication.
c. Place the child in a therapeutic hold.
d. Call a staff member to seduce the child.
Answer: A
Question: An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse’s interview, the employee says, “My partner beat me, but it was because there are problems at work.” What should the nurse’s next action be?
Answer Options:
a. Notify the police.
b. Refer the employee to a shelter.
c. Notify the adult protective agency.
d. Document injuries with a body map.
Answer: d. Document injuries with a body map.
Question: The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient’s discharge?
Answer Options:
a. Patient states, “I feel safe and entirely relaxed.”
b. Memory of the rape is less vivid and frightening.
c. Physical symptoms of pain and discomfort are no longer present.
d. Patient agrees to keep a follow-up appointment with the rape crisis center.
Answer: d. Patient agrees to keep a follow-up appointment with the rape crisis center.
Question: After the death of his wife, a man tells the nurse, “I can’t live without her. She was my whole life.” Which is the nurse’s most therapeutic response?
Answer Options:
a. “Each day will get a little better.”
b. “Her death is a terrible loss for you.”
c. “Remember, she’s no longer suffering.”
d. “Your friends will help you cope with this.”
Answer: b. “Her death is a terrible loss for you.”
Question: A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, “I want to go to school but we can’t afford a babysitter. It doesn’t matter; I’m too dumb to learn.” What preliminary assessment is evident?
Answer Options:
a. Insufficient data are present to make an assessment.
b. Child and siblings are experiencing neglect.
c. Children are at high risk for sexual abuse.
d. Children are experiencing physical abuse.
Answer: b. Child and siblings are experiencing neglect.
Question: A nurse counsels a person whose spouse recently died. The nurse uses cheer and humor to lift the person’s spirits. At one point, the widowed person smiles briefly. What analysis of this scenario is correct?
Answer Options:
a. The nurse’s technique was effective.
b. Use of humor should be added to the plan of care.
c. This approach may prove useful in other, similar situations.
d. The nurse needs help developing therapeutic communication skills.
Answer: d. The nurse needs help developing therapeutic communication skills.
Question: A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic?
Answer Options:
a. Neutrally permit refusals.
b. Coax to gain compliance.
c. Offer rewards in advance.
d. Establish firm limits.
Answer: D
Question: A nurse working a rape telephone hotline should focus communication efforts toward what intervention?
Answer Options:
a. Arranging long-term counseling
b. Serving as a sympathetic listener
c. Obtaining information to relay to the local police
d. Explaining immediate steps that a victim of rape should take
Answer: d. Explaining immediate steps that a victim of rape should take
Question: A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, “I have three good friends at school. We talk and sit together at lunch.” What is the nurse’s best suggestion to the treatment team?
Answer Options:
a. Suggest foster home placement.
b. Seek assistance from an intimate partner violence program.
c. Make referrals for existing and emerging developmental resources in the community.
d. Encourage healthy characteristics and existing emotional supports. No other action is necessary or appropriate under the current circumstances.
Answer: D
Question: A terminally ill patient says, “I know I’m not going to get well, but still.” and the patient’s voice trails off. Which response by the nurse is therapeutic?
a. “What do you hope for?”
b. “No, you’re not going to get well.”
c. “Do you have questions about what is happening?”
d. “I’m happy you are being realistic about your future.”
Answer: a. “What do you hope for?”
Question: The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention?
Answer Options:
a. Encourage discussion of the assault to help validate the victim’s feelings.
b. Teach the victim self-defense techniques to prevent future assaults.
c. Assist the victim in understanding why this event occurred.
d. Offer sedation to promote rest and decrease anxiety.
Answer: a. Encourage discussion of the assault to help validate the victim’s feelings.
Question: A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, “I can’t believe I’ve been raped.” This behavior is characteristic of which phase of the rape trauma syndrome?
Answer Options:
a. Anger phase
b. Acute phase
c. Outward adjustment phase
d. Long-term reorganization phase
Answer: b. Acute phase
Question: What is the primary motivator for most rapists?
Answer Options:
a. Anxiety
b. Need for humiliation
c. Overwhelming sexual desires
d. Desire to inflict violence or control others
Answer: d. Desire to inflict violence or control others
Question: What is a nurse’s legal responsibility if child abuse or neglect is suspected?
Answer Options:
a. Discuss the findings with the child’s teacher, principal, and school psychologist.
b. Report the suspected abuse or neglect according to state regulations.
c. Document the observations and speculations in the medical record.
d. Continue the assessment.
Answer: b. Report the suspected abuse or neglect according to state regulations.
Question: After treatment for a detached retina, a victim of intimate partner violence says, “My partner only abuses me when intoxicated. I’ve considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me.” Which nursing diagnosis applies?
Answer Options:
a. Social isolation, related to lack of community support system
b. Risk for injury, related to partner’s physical abuse when intoxicated
c. Deficient knowledge, related to resources for escape from the abusive relationship
d. Disabled family coping, related to uneven distribution of power within a relationship
Answer: b. Risk for injury, related to partner’s physical abuse when intoxicated
Question: A victim of intimate partner violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on what?
Answer Options:
a. Supporting emotional security and re-establishing equilibrium
b. Offering long-term resolution of issues precipitating the crisis
c. Promoting growth of the individual
d. Providing legal assistance
Answer: a. Supporting emotional security and re-establishing equilibrium
Question: A rape victim tells the nurse, “I should not have been out on the street alone.” Which is the nurse’s most therapeutic response?
Answer Options:
a. “Rape can happen anywhere.”
b. “Blaming yourself only increases your anxiety and discomfort.”
c. “You believe this would not have happened if you had not been alone.”
d. “You are right. You should not have been alone on the street at night.”
Answer: a. “Rape can happen anywhere.”
Question: A nurse assesses a patient who reports feeling depressed and hopeless after trying to determine the patient’s perception of the precipitating event. What should the nurse ask that would be most therapeutic?
Answer Options:
a. “Tell me why you were crying.”
b. “How did your wrist get injured?”
c. “How can I help you feel more comfortable?”
d. “What was happening just before you started feeling this way?”
Answer: d. “What was happening just before you started feeling this way?”
Question: A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? (Select all that apply.)
Answer Options:
a. Difficulty using a cell phone
b. Long-term memory losses
c. Fecal incontinence
d. Rapid speech
e. Trembling
Answer: a. Difficulty using a cell phone
d. Rapid speech
e. Trembling