A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome?
a. The acute phase reaction
b. The long-term phase
c. A delayed reaction
d. The angry stage
ANS: A
The victim's response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction.
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The daughter of an elderly man notices that her father has stopped seeing his friends for their daily walk and acts in an aggressive manner when anyone comes to his house
She states that he normally looks forward to interacting with his friends on a daily basis, and his general demeanor is friendly and caring. What does the nurse advise? a. This is a normal part of aging and there should be no reason for concern. b. The change in personality and behavior should be ignored as it is manipulative. c. The change in personality and behavior should be evaluated. d. The change in personality and behavior indicates it is time for nursing home placement.
A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care?
A) Elevate the head of the bed to 45 degrees. B) Maintain the patient on complete bed rest. C) Administer enemas when the patient is constipated. D) Avoid use of thigh-high elastic compression stockings.
Which of the following urine specific gravity readings indicates dehydration?
1. 1.000 2. 1.020 3. 1.030 4. 1.050
The nurse will place an infant experiencing an apnea episode in the "sniffing position," which is to
a. Lower the head and flex the neck b. Lean the child over a pillow and gently pat the back c. Place the child in a supine position and flex the knees d. Elevate the head and hyperextend the neck