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:
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
2.
During the initial care of rape victims the following are to be considered EXCEPT:
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.
3.
The nurse acts as a patient advocate when she does one of the following:
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
4.
Crisis intervention carried out to the client has this primary goal:
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
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:
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
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:
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
7.
Anxiety is caused by:
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
8.
It would be most helpful for the nurse to deal with a client with severe anxiety by:
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.
9.
Which of the following medications will likely be ordered for the client?”
Correct Answer
B. Vaium
Explanation
Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic
10.
Which of the following is included in the health teachings among clients receiving Valium?:
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.