A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?

Correct Answer: C

Rationale: The correct answer is C because the patient's behavior indicates a possible experience of auditory hallucinations. The patient covering both ears and shaking her head could be an attempt to block out voices or sounds she is hearing. The subsequent crying and muttering could be a response to these hallucinations. Choice A is incorrect because the patient's behavior does not necessarily indicate a desire for attention. Choice B is incorrect because the patient's emotional expression is not the primary focus of the behavior. Choice D is incorrect because negative symptoms of schizophrenia typically involve a decrease in emotional expression or motivation, which is not evident in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Rape should not be discussed. This belief contributes to a negative family response because it promotes silence and stigma around the topic of rape, leading to lack of support and understanding for the victim. By not discussing rape, the victim may feel isolated, ashamed, and unable to seek help or share their experience. Choices A and B are incorrect as they acknowledge the victim's innocence and the violent nature of rape. Choice D is incorrect as it recognizes the reality that anyone can be a victim, but it does not directly address the issue of discussing rape within the family.

Correct Answer: B

Rationale: The correct answer is B because research shows that perpetrators of interpersonal violence are most often someone the victim knows, such as a partner, family member, or acquaintance. This is supported by studies and data that indicate a significant majority of interpersonal violence cases involve perpetrators who have a prior relationship with the victim. Choice A is incorrect because while substance abuse can be a factor in some cases, it is not the primary characteristic of perpetrators. Choice C is incorrect as statistics show that perpetrators are usually known to the victim rather than being strangers. Choice D is also incorrect as psychotic states are not typically the primary cause of interpersonal violence, and most perpetrators are not in such a state during the act.

Correct Answer: A

Rationale: The correct answer is A because taking photographs of trauma areas can provide crucial evidence for legal and medical purposes. It can help document the extent of injuries and aid in the prosecution of the abuser. This step is essential in ensuring proper documentation and care for the victims. Option B is incorrect because assessing for sexually transmitted diseases may not be the immediate priority in cases of domestic violence. Option C is incorrect as following rape protocol when rape is not suspected may not be necessary and could potentially retraumatize the victim. Option D is incorrect because making protective services aware of the abuse should only be done with the victim's consent to ensure their safety and autonomy.

Correct Answer: B

Rationale: The correct answer is B because in stage 1 Alzheimer's, individuals can still maintain a relatively high level of functionality. This is because in the early stages, the cognitive decline is mild and individuals can still perform daily tasks independently. It is important to focus on maximizing the client's functional abilities through cognitive exercises and support services. Choice A is incorrect because long-term placement may not be necessary in stage 1 and should only be considered if the caregiver's health is at risk. Choice C is incorrect because individuals with Alzheimer's should be encouraged to make decisions to maintain their sense of autonomy. Choice D is incorrect because Alzheimer's is a progressive disease that affects both cognitive and physical functions over time.