An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?
1. Encourage exploration of sexual abuse.
2. Encourage guided imagery.
3. Establish trust and rapport.
4. Administer antianxiety medications.
3
Rationale: The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with DID. DID was formerly called multiple personality disorder. Trust is the basis of every therapeutic relationship. Each personality views itself as a separate entity and must be treated as such to establish rapport.
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You are working in Labor and Delivery and assessing the father-to-be for signs that he is adapting to his role. Which of the following would indicate that the father is adapting? (Select all that apply.)
a. He participates in identifying childcare op-tions. b. He coaches her, encourages her, and shares her experience. c. He tells you that he is eager to hold his baby as soon as the baby is born. d. He physically soothes the other by massaging her back. e. He sits by the bed reading a magazine and refusing to touch her. f. He tells the mother to stop complaining be-cause he knows the pain is not that bad.
An instructor explains precautions that nurses can take when dealing with the possibility of exposure to blood and bodily fluids. The instructor identifies that additional guidance is needed when a student says:
1. "I always place my used needles into a puncture-proof, labeled container." 2. "I always recap my used needles before disposing of them." 3. "I always wash my hands before and after patient contact." 4. "I always wear gloves if there is a chance for exposure to bodily fluids."
A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn?
a. Buttocks b. Tip of nose and sclera c. Sclera, conjunctiva, and oral mucosa d. Palms of hands and soles of feet
The nurse is caring for an immune compromised patient. The patient displays a low-grade fever and complains of a burning and shooting pain, along with itching and tingling, that progresses from the clavicle to the scapula
The nurse suspects that the patient will undergo evaluation for which infection? a. Hepatitis C b. Shingles c. Candidiasis d. Cryptococcosis