A client in the long-term reorganization phase of the rape-trauma syndrome is experiencing intrusive
thoughts of the rape and over the past week has developed a fear of being alone.
Indicators for the
outcome of fear self-control that should be monitored by the nurse include the client
a. planning coping strategies for fearful situations.
b. using increased activity to reduce fear.
c. temporarily withdrawing from social situations.
d. expressing willingness to be sexual.
A
This indicator shows willingness and ability to take personal action to reduce disabling fear. Options
B and C are not desirable. Option 4 is an indicator related to the outcome of sexual functioning
rather than fear self-control.
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The emergency department nurse realizes that the husband of a patient appears increasingly irritable as he waits alone in the waiting room. Which intervention would best prevent further escalation?
a. Periodically update the husband about his wife and what is being done for her. b. Explain that waiting is necessary because patients are treated in order of need. c. Reassure him that everything possible is being done and suggest ways to relax. d. Suggest that he return home and await an update from the physician in 3 hours.
While administering intravenous immune globulin (IVIG), the nurse assesses vital signs and for adverse reactions every 15 minutes for the first hour of administration. After the first hour, how should the nurse continue to assess the child?
A) Every 45 minutes through the remainder of the infusion B) Every 30 minutes C) Per institutional protocol D) On a case-by-case basis
While assessing a patient's pulse, a nurse identifies that the pulse obliterates. This means the pulse
1. Is full and has a bounding quality. 2. Is weak, faint, and not perfusing. 3. Disappears upon palpation. 4. Indicates contractions are perfusing.
A nurse is working with the family of a woman who was sexually assaulted by a colleague. Family members have expressed guilt, fear, and anger about the assault. The nurse knows teaching has been successful when a member of the family states:
A) "The way a woman dresses affects her risk for sexual violence." B) "People must refrain from going to a date's residence early in a relationship." C) "Women are more affected by rape than men are." D) "The average woman is unlikely to be able to escape the person intent on committing sexual assault."