A female comes to the Emergency Department with a broken wrist and severe bruises from a beating by her husband. She states that she does not want to leave the relationship at this time. The most appropriate response by the nurse is:

will help you leave this relationship"

You need to report your husband to the police"

Let's develop a safety plan for repeated violence"

Here is a list of services that can help you"

Answer and Explanation

The Correct Answer is C

A. "I will help you leave this relationship" is not an appropriate response because it assumes the nurse knows what is best for the patient and does not respect her autonomy or immediate choices. The patient has clearly stated she does not want to leave the relationship at this time.
B. "You need to report your husband to the police" is an invasive and potentially coercive statement. While reporting abuse is important, the nurse should provide information and support, not force actions the patient may not be ready to take. Pressuring her could escalate the situation and harm the patient’s trust in healthcare providers.
C. "Let's develop a safety plan for repeated violence" is the most supportive and patient-centered response. It acknowledges the reality of the abuse while offering a non-judgmental, practical approach to help her stay safe. The nurse is giving the patient the option to make informed decisions about her safety, which is empowering.
D. "Here is a list of services that can help you" is helpful, but it lacks the active engagement the patient may need. Developing a personalized safety plan is more immediate and relevant for someone experiencing ongoing abuse.

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Correct Answer is C

Explanation

A. Sweating is a common symptom of opioid withdrawal and is included in the Clinical Opiate Withdrawal Scale (COWS), which is used to assess the severity of withdrawal symptoms.
B. Goosebumps (also called piloerection) are a classic physical sign of opioid withdrawal and are specifically assessed in the COWS scoring system.
C. Palpitations are not typically listed as a core symptom of opioid withdrawal in the COWS assessment. While some individuals may subjectively report feeling anxious or having an increased heart rate, palpitations are not a primary or consistent withdrawal symptom.
D. High blood pressure is a recognized symptom of opioid withdrawal and is measured in the COWS tool as part of autonomic symptoms like increased pulse and blood pressure.

A. Client will remain free from self-directed violence as evidenced by agreement to a no-suicide contract. B. Client will have intact tactile senses as evidenced by ability to recognize familiar objects when placed in his or her hand. C. Client will have decreased confusion as evidenced by orientation to person, place, and time. D. Client will verbalize increased feelings of self-esteem as evidenced by statements acknowledging ability to perform certain tasks independently.

Correct Answer is C

Explanation

A. Client will remain free from self-directed violence as evidenced by agreement to a no-suicide contract is more appropriate for a patient who is at risk for suicide or self-harm, but it doesn't specifically address delirium, which involves acute confusion and altered consciousness. A no-suicide contract does not directly address the underlying cognitive issues in delirium.
B. Client will have intact tactile senses as evidenced by ability to recognize familiar objects when placed in his or her hand focuses on sensory perception, which may not be the most relevant outcome for a patient experiencing delirium. Delirium primarily affects cognitive functions such as attention, memory, and orientation, rather than tactile sensations.
C. Client will have decreased confusion as evidenced by orientation to person, place, and time is the most appropriate and specific outcome for delirium. Delirium is characterized by acute confusion and disorientation to time, place, and person, and improving orientation is a key goal in managing delirium.
D. Client will verbalize increased feelings of self-esteem as evidenced by statements acknowledging ability to perform certain tasks independently is more relevant for mental health disorders such as depression or anxiety, where self-esteem and independence are key focuses. While important, it is not a priority outcome for delirium, where the main concern is restoring cognitive function.

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A female comes to the Emergency Department with a broken wrist and severe bruises from a beating by her husband. She states that she does not want to leave the relationship at this time. The most appropriate response by the nurse is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

All of the following are symptoms of opiate abuse withdrawal (COWS) except

Correct Answer is C

Explanation

Which of the following is an appropriate outcome for a client experiencing an acute episode of delirium?

Correct Answer is C

Explanation

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Which of the following is not characteristic of cognitive impairment?

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All of the following medications can be used for alcohol withdrawal except

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