Which statement by a client who is severely and persistently mentally ill would the nurse assess as providing a priority need for intervention?
1. "I only have sex with men who use condoms."
2. "My husband still wants to have sex with me."
3. "I go to the clinic yearly to have a PAP smear."
4. "I had my tubes tied so I can't get pregnant."
ANS: 1
Option 1 suggests that the client may be promiscuous because she speaks of sex with men rather than one partner. Promiscuity places the client at increased risk for rape, other violence, and sex-ually transmitted diseases. The other options provide opportunities for teaching but are not as high priority for discussion as option 1.
You might also like to view...
A fellow nurse reports a strange experience: She was riding with her carpool partner after working her second double shift in a row when she looked down at her hands on her lap and did not immediately recognize them as her own
They seemed "small and far away" to her. She felt "like I wasn't myself" for several minutes, after which she gradually returned to normal. This happened several weeks ago, and she has never had a similar experience otherwise. She is worried she is losing her mind or suffering from a brain tumor. Which response most accurately reflects what the friend probably experienced? a. Not accepting part of one's body as one's own is an indication of body dysmorphic disorder; this is a psychiatric disorder and prompt treatment is needed. b. The long hours of work with little recovery time led her to have a transient episode of depersonalization; these are common, stress-related, and not a sign of major illness. c. The friend had a mini-fugue experience, which suggests deeper underlying conflicts or past trauma that has not resolved; it could progress and merits counseling. d. Such feelings of unreality could be early symptoms of dissociative identity disorder; she might not have recognized her own body because an alter personality was taking control.
A pregnant woman at 30 weeks' gestation tells the nurse that she dropped a pan last week and her baby jumped at the noise. Which of the following responses by the nurse is most accurate?
a. "Let me know if it happens again, since we need to report that to your health care provider." b. "Babies respond to sound starting at about the twenty-fourth week of gestation." c. "The fetus is demonstrating the aural reflex." d. "That movement was just a coincidence; unborn babies can't respond to sound like that."
Which assessment finding will alert the nurse to suspect early digitalis toxicity?
a. Loss of appetite with slight bradycardia b. Blood pressure 90/60 mm Hg c. Heart rate 110 beats per minute d. Confusion and diarrhea
Which of the following types of leukemia carries the best prognosis?
a. Acute lymphoblastic leukemia b. Acute myelogenous leukemia c. Basophilic leukemia d. Eosinophilic leukemia