A nurse is working with a perpetrator of family violence who has a long history of violent rages when frustrated, with periods of remorse after each outburst. The nurse is most likely to establish the nursing diagnosis of:

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Question 1 of 5

A nurse is working with a perpetrator of family violence who has a long history of violent rages when frustrated, with periods of remorse after each outburst. The nurse is most likely to establish the nursing diagnosis of:

Correct Answer: C

Rationale: The correct answer is C: Ineffective coping related to poor anger management. This nursing diagnosis is appropriate because it addresses the perpetrator's inability to manage their anger effectively, leading to violent outbursts. The perpetrator's history of violent rages and subsequent remorse suggest a pattern of maladaptive coping mechanisms. This diagnosis focuses on the underlying issue of poor anger management, which is essential to address in order to prevent future acts of violence. Choices A, B, and D are incorrect: A: Risk for injury related to victim reprisal - This choice places the focus on potential harm to the victim as a result of retaliation, which is not the primary issue in this scenario. B: Risk for other-directed violence related to stress - While stress may contribute to the perpetrator's behavior, the primary issue lies in their poor anger management rather than just stress. D: Caregiver role strain related to feelings of being overwhelmed - This choice is not appropriate as it does not address the core issue of poor

Question 2 of 5

A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient's underclothes. Priority actions by the nurse should focus on:

Correct Answer: B

Rationale: The correct answer is B: Maintaining the patient's airway. This is the priority action because the patient is unconscious and airway patency is crucial for survival. Preserving rape evidence (A) can be important, but the patient's immediate health takes precedence. Obtaining a description of the rape (C) can wait until the patient's condition stabilizes. Determining what drugs were ingested (D) is important but secondary to ensuring the patient can breathe.

Question 3 of 5

A community health nurse is working with a family in which an elderly woman was neglected by her son and his wife. The elderly woman insists on remaining with the young couple despite the threat of future neglect. Which intervention should be given highest priority?

Correct Answer: B

Rationale: The correct answer is B because establishing family obligations, client rights, and consequences of abuse is crucial in protecting the elderly woman from neglect. By setting clear boundaries and educating the family on their responsibilities and the consequences of neglect, the nurse can help ensure the woman's safety. This intervention addresses the root cause of the issue and empowers the family to understand and fulfill their duties. Choice A is incorrect as solely focusing on decreasing caregivers' stress may not address the underlying neglect. Choice C is incorrect as educating caregivers on the aging process does not directly address the neglect issue. Choice D is incorrect as providing stress management techniques does not address the root cause of neglect or establish accountability within the family.

Question 4 of 5

The nurse is planning care for a battered woman who has mentioned, 'Someday I'll have to leave him.' Which outcome should the nurse include in the plan of care for this client?

Correct Answer: D

Rationale: The correct answer is D: Client will verbalize awareness of the dangerousness of her situation. This outcome is crucial as it indicates the client's understanding of the risks involved in her current situation. By verbalizing awareness, the client is acknowledging the potential harm and taking a significant step towards recognizing the need for change. This outcome lays the foundation for further interventions and support. Choice A is incorrect because setting a specific timeline for leaving may not be feasible or safe for the client. Choice B is incorrect as feeling relaxed does not necessarily address the underlying issue of abuse. Choice C is incorrect as feeling strong does not necessarily equate to recognizing the dangers of the situation. The focus should be on increasing awareness and empowering the client to make informed decisions.

Question 5 of 5

The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse assesses the client's stage of Alzheimer's disease as stage:

Correct Answer: B

Rationale: The correct answer is B (stage 2) because the client is exhibiting symptoms of moderate Alzheimer's disease, such as paranoia and delusions. In stage 2, cognitive decline becomes more noticeable, leading to memory loss, confusion, and behavioral changes. The client's accusations and false beliefs indicate a decline in reality orientation, which is characteristic of stage 2. Choices A, C, and D are incorrect because stage 1 is characterized by mild cognitive decline, stage 3 by severe cognitive decline, and stage 4 by very severe cognitive decline.

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