The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge?
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 victim advocate.
ANS: D
Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.
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The rationale for giving the patient additional fluids after a cardiac catheterization is that
a. fluids help keep the femoral vein from clotting at the puncture site. b. the patient had a nothing-by-mouth order before the procedure. c. the radiopaque contrast acts as an osmotic diuretic. d. fluids increase cardiac output.
The nurse is caring for a patient who is suffering from severe depression. How can the nurse best help the patient find meaning in the experience of suffering from mental illness?
1. Suggest answers when the patient questions the meaning of life. 2. Listen and be present when the patient questions the meaning of life. 3. Listen and offer answers when the patient questions the meaning of life. 4. Encourage the patient to discuss well-formulated answers to the meaning of life.
When the paranoid schizophrenic states that his whole family has conspired to have him put in the hospital and that the medical staff is part of the conspiracy, the nurse's most therapeutic re-sponse would be:
a. "I'm not like that. I want to help you." b. "You know your family is concerned about you." c. "I'm sorry you feel that way. I'll be around if you want to talk about your feelings." d. "The doctors are trying to help you feel better. They have your best interest in mind."
Following a fall, a patient is brought to the emergency department. There was a brief loss of consciousness. The patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area,
and is currently having a seizure. What should the nurse anticipate regarding the care of this patient? 1. This is an emergency situation that is likely due to an epidural hematoma and requires surgery. 2. This is a controlled situation once the seizure stops. 3. This is a serious situation in which a subdural hematoma is developing and requires surgery. 4. This is a typical situation seen with most patients who fall and will subside with observation.