NURS 218 Personal Care of Head Emergencies at Baton Rouge Community College
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Free NURS 218 Personal Care of Head Emergencies at Baton Rouge Community College Questions
Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.)
- A. The patient's history of sexually transmitted diseases
- B. Coping mechanisms the patient is using
- C. Signs and symptoms of emotional and physical trauma
- D. The patient's previous sexual experiences
- E. Adequacy and availability of the patient's support system
Explanation
C. Signs and symptoms of emotional and physical trauma The immediate priority when interviewing a rape victim is to assess for both emotional and physical trauma. The nurse must evaluate the severity of injuries and address any life-threatening physical trauma. Emotional trauma, such as shock, dissociation, and fear, should also be assessed to ensure the victim receives appropriate psychological support.
E. Adequacy and availability of the patient's support system Assessing the availability of a support system is essential in determining the next steps for the patient's recovery. The nurse needs to understand if the victim has a reliable and supportive network to help them cope with the trauma. Social support can play a crucial role in healing and providing safety after the assault.
A nurse teaches caregivers of clients with autism. Which statement by the caregiver indicates a need for more teaching?
- A. "This client will benefit from routine in their environment."
- B. "We need to make sure this child experiences new things every day."
- C. "We need to protect this child from scratching using mittens."
- D. "We need to reward the client for making eye contact with us."
Explanation
Children with autism often thrive in structured environments with routines, as it helps reduce anxiety and supports their understanding of expectations. While exposure to new experiences can be beneficial, introducing too many new things every day can overwhelm them and increase stress. The focus should be on gradually introducing new experiences, within a predictable and supportive structure. The other statements align more closely with appropriate strategies: maintaining routine, using positive reinforcement (like rewarding eye contact), and using alternative strategies to address behaviors such as scratching, instead of restricting movement with mittens.
A nursing student on the behavioral health unit says, "These patients with Schizophrenia and schizotypal personality disorder! What's the difference?". The nurse's response should include which information?
- A. A patient diagnosed with schizophrenia is not usually overtly psychotic
- B. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality
- C. In schizotypal personality disorder, the patient remains psychotic much longer
- D. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia
Explanation
Schizotypal personality disorder (STPD) involves eccentric behaviors and odd beliefs but does not typically involve full psychosis like schizophrenia. People with STPD can often be made aware of their misinterpretations of reality. They may experience mild distortions in perception or thinking but are usually capable of reality testing and can understand that their beliefs are unusual. In contrast, schizophrenia often involves more severe cognitive distortions, hallucinations, and delusions that are difficult for the person to recognize as irrational.
A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt?
- A. Excessive crying
- B. Giving away sweaters
- C. Staying alone in dorm room
- D. Calling parents
Explanation
Giving away personal belongings, especially valued items like expensive sweaters, is often seen as a significant warning sign of suicidal intent. It may indicate that the individual feels a sense of finality or detachment and is preparing for something irreversible. This behavior suggests that the person may be contemplating suicide, as they are symbolically "letting go" of possessions that hold personal value. This act is a strong indicator that immediate intervention is needed.
A nurse is providing teaching to an adolescent patient who is to begin taking atomoxetine (Strattera) for Attention Deficit Hyperactivity Disorder. The nurse should instruct the patient to monitor for which adverse effect?
- A. Increased appetite
- B. Somnolence
- C. Yellowing skin
- D. Weight gain
Explanation
Atomoxetine (Strattera) is a non-stimulant medication used to treat Attention Deficit Hyperactivity Disorder (ADHD). A rare but serious adverse effect of atomoxetine is liver damage, which can present with symptoms like yellowing of the skin (jaundice) or eyes. The nurse should instruct the patient to monitor for any signs of liver problems, such as yellowing of the skin, and report them immediately, as this could indicate liver toxicity.
The nurse describes a patient as very shy and lacking in self-confidence, staying alone all day, and refusing to come out for lunch. Which term best describes this behavior?
- A. Avoidant
- B. Histrionic
- C. Narcissistic
- D. Paranoid
Explanation
Avoidant personality disorder is characterized by feelings of inadequacy, extreme sensitivity to criticism, and a strong desire for social relationships, but with a fear of rejection or failure. This leads to social withdrawal, shyness, and isolation. The described behavior of the patient — being shy, lacking self-confidence, and staying alone — fits the pattern of avoidant traits, where individuals tend to avoid social situations due to fear of negative evaluation or rejection.
A client with attention-deficit hyperactivity disorder is assessed by a nurse. Which assessment findings are expected? Select all that apply.
- A. Distractibility
- B. Increased attention to detail
- C. Increased level of activity
- D. A history of accidental injuries
- E. Reluctance to talk
- F. Impulsiveness
Explanation
A. Distractibility Distractibility is a hallmark symptom of ADHD. Individuals with ADHD often have difficulty staying focused on tasks or activities, leading them to become easily distracted by external stimuli or irrelevant thoughts. This constant shifting of attention interferes with their ability to complete tasks, whether at school, work, or home.
C. Increased level of activity Hyperactivity is a core feature of ADHD. This manifests as an excessive need for movement or fidgeting, difficulty staying still, and being constantly on the go. This increased level of activity can be evident in both children and adults with ADHD and may result in challenges in situations that require prolonged focus or calm behavior, such as in classrooms or meetings.
D. A history of accidental injuries Due to impulsivity and hyperactivity, individuals with ADHD are at an increased risk of accidents. They may act without considering the consequences, making them more prone to injuries. Additionally, their constant movement and inability to focus on safety can lead to frequent accidents or mishaps, which can be reflected in a history of injuries.
F. Impulsiveness Impulsivity is a central feature of ADHD. This can lead to actions taken without thinking through the consequences, such as interrupting others, making decisions without adequate consideration, or engaging in risky behaviors. Impulsive behaviors can also extend to difficulty waiting for one's turn or acting inappropriately in social situations.
A child has been placed on central nervous system (CNS) stimulants for attention-deficit hyperactivity disorder (ADHD). The nurse should include which side effects of the medication while teaching the parents?
- A. Growth retardation, urinary retention, and bradycardia
- B. Nervousness, nausea and vomiting, and dystonia
- C. Headache, insomnia, and possible growth retardation
- D. Bradycardia, weight gain, and insomnia
Explanation
CNS stimulants, such as methylphenidate and amphetamines, are commonly prescribed for ADHD. The most common side effects include headache, insomnia (difficulty sleeping), and potential growth retardation (slowed growth or weight gain). These side effects occur due to the stimulating effects of the medication on the central nervous system. Parents should be made aware of these potential side effects and should monitor the child's response to medication, including any changes in growth patterns or sleep disturbances.
A patient with a tracheostomy is experiencing thick, tenacious secretions and labored breathing. What is the nurse's priority intervention?
- A. Administer an antitussive
- B. Suction the tracheostomy
- C. Notify the health care provider
- D. Increase oxygen flow rate
Explanation
The priority intervention for a patient with a tracheostomy who is experiencing thick, tenacious secretions and labored breathing is to suction the tracheostomy. Suctioning helps clear the airway and remove the secretions that are obstructing breathing. This intervention is critical for maintaining airway patency and improving respiratory function. After suctioning, further actions may be necessary, such as notifying the healthcare provider or adjusting oxygen therapy, depending on the patient’s response.
A nurse is caring for a school-age child who has conduct disorder and a new prescription for methylphenidate (Daytrana) transdermal patches. What information should the nurse provide about the medication?
- A. Apply the patch once daily at bedtime
- B. Remove the patch each day after 9 hours
- C. Place the patch carefully in a trash can after removal
- D. Apply the transdermal patch to the anterior waist area
Explanation
Methylphenidate (Daytrana) is a transdermal patch used to treat Attention Deficit Hyperactivity Disorder (ADHD) and other conditions like conduct disorder. The patch should typically be applied once a day, in the morning, and worn for up to 9 hours. It is important to remove the patch after 9 hours to avoid prolonged exposure to the medication, which can lead to side effects such as insomnia or decreased appetite.
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