A patient, aged 16 years, comes to the crisis clinic and tells the nurse that an uncle tried to rape her yesterday
The patient had told her mother of the uncle's behavior, but the mother accused the daughter of lying and, contrary to the patient's hopes, indicated she would still allow the uncle to visit the family. The patient describes feeling "all confused" and shows minor lacerations on her forearms to the nurse, which she indicates she did out of desperation rather than a wish to die. Which nursing diagnosis would be most appropriate as her primary diagnosis? a. Powerlessness
b. Disturbed thought processes
c. Rape-trauma syndrome
d. Interrupted family process
A
The patient, a teenager, has relatively little control over her circumstances compared to her parents. However, when she approached her parent seeking support and protection, she was instead rebuffed and identified as the perpetrator rather than the victim. The patient made an effort to exert the power available to her by reporting the attempted assault, only to be accused herself and have the protection she desired withheld. Of the diagnoses listed, the most applicable would be powerlessness. There are no data to support an alteration in thought processes or interruption in family process. Rape-trauma syndrome involves posttraumatic stress disorder–like symptoms that include flashbacks and intrusive thoughts, none of which are documented here.
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A client in apparent cardiac arrest has been brought to the emergency department (ED) by emergency medical services. The ED nurse immediately recognizes the need to implement the principles of the Chain of Survival
During which of the components of the Chain of Survival will medications be administered to the client? A) Early CPR B) Rapid defibrillation C) Effective advanced life support D) Rapid cardiac assessment
The most important nursing intervention for patients who receive neuromuscular blocking agents is to:
a. administer sedatives in conjunction with the neuromuscular blocking agents. b. assess neurological status every 30 minutes. c. avoid interaction with the patient, because he or she won't be able to hear. d. restrain the patient to avoid self-extubation.
The patient is an 83-year-old gentleman who has the beginning stages of dementi
a. To prevent the patient from falling or "escaping," the nurse should: a. Have the patient stay in his room b. Have the family take all of the patient's belongings home c. Allow the patient to be as independent as possible d. Give the patient antianxiety medication
A well-made bed is important to good patient care and well-being.
Answer the following statement true (T) or false (F)