A nurse is assessing a 30-year-old female client who has recently disclosed a history of sexual violence. Which of the following nursing interventions should be prioritized to support this client’s immediate needs?
Encourage the client to discuss her feelings in detail to facilitate emotional processing
Suggest the client return for weekly therapy sessions to explore her trauma in a safe environment
Provide the client with information about support groups for survivors of sexual violence
Develop a safety plan that includes coping strategies for anxiety and resources for immediate support
The Correct Answer is D
Choice A reason: Encouraging detailed discussion of feelings may be harmful initially, as it risks re-traumatization. Sexual violence triggers intense stress responses, increasing amygdala activity and cortisol levels. Scientifically, forcing trauma processing before establishing safety can exacerbate anxiety and PTSD symptoms, delaying recovery by overwhelming the client’s emotional regulation capacity.
Choice B reason: Weekly therapy is beneficial for long-term trauma processing but not an immediate priority. Sexual violence survivors need acute stabilization first, addressing safety and coping. Scientifically, therapy requires emotional readiness, as premature exploration may heighten stress responses, increasing risk of PTSD or dissociation without immediate safety measures.
Choice C reason: Support groups provide peer connection but aren’t the immediate priority post-disclosure. Survivors need safety and coping strategies first to manage acute anxiety. Scientifically, group settings may overwhelm clients early in recovery, as social exposure can trigger stress responses, delaying stabilization of trauma-related neurobiological changes like hyperarousal.
Choice D reason: A safety plan with coping strategies and resources addresses immediate needs post-sexual violence. It reduces anxiety through practical tools like breathing exercises, calming the amygdala and lowering cortisol. Scientifically, ensuring safety mitigates trauma’s neurobiological impact, stabilizing emotional regulation and preventing further harm, making it the most urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Two tablets (1 mg) underdose the prescribed 2 mg. Risperidone, an antipsychotic, balances dopamine and serotonin for schizophrenia or bipolar disorder. Scientifically, insufficient dosing fails to stabilize neural activity, risking symptom persistence, like hallucinations, due to inadequate receptor modulation, compromising mental health treatment efficacy.
Choice B reason: One tablet (0.5 mg) significantly underdoses the 2 mg requirement. Risperidone’s therapeutic effect relies on adequate dopamine antagonism. Scientifically, subtherapeutic levels leave psychotic symptoms uncontrolled, as insufficient receptor blockade fails to reduce neural hyperactivity, increasing risks of agitation or psychosis relapse.
Choice C reason: Four tablets (2 mg) match the prescribed dose, ensuring therapeutic dopamine and serotonin modulation. Scientifically, accurate Risperidone dosing stabilizes neural activity, reducing psychotic symptoms like hallucinations. This optimizes antipsychotic efficacy, preventing symptom exacerbation while avoiding side effects from overdosing, supporting mental health stability.
Choice D reason: Three tablets (1.5 mg) underdose the required 2 mg, reducing efficacy. Risperidone’s antipsychotic effects depend on precise receptor antagonism. Scientifically, inadequate dosing fails to control dopamine-driven symptoms, risking psychosis or agitation, as neural hyperactivity persists, compromising treatment outcomes for schizophrenia or bipolar disorder.
Correct Answer is D
Explanation
Choice A reason: Advising more water is inappropriate without assessing confusion’s cause. Dehydration may contribute, but confusion in the elderly often stems from medication or infection. Scientifically, unaddressed causes like polypharmacy or neuroinflammation risk worsening cognitive impairment, delaying effective intervention and patient stabilization.
Choice B reason: Suggesting a nap doesn’t address confusion’s underlying cause. Cognitive impairment may reflect medication effects or delirium. Scientifically, rest alone fails to mitigate neurochemical or inflammatory triggers, like acetylcholine deficits, risking prolonged confusion and delaying identification of critical medical issues in elderly patients.
Choice C reason: Calling emergency services is premature without assessment. Confusion may stem from medication or mild delirium, not requiring immediate hospitalization. Scientifically, hasty action risks unnecessary stress, elevating cortisol, while a targeted review identifies reversible causes, ensuring appropriate intervention for cognitive stabilization.
Choice D reason: A medication review identifies polypharmacy or side effects causing confusion. Many elderly patients take medications affecting acetylcholine or dopamine, leading to delirium. Scientifically, reviewing medications pinpoints reversible causes, stabilizing cognitive function and preventing further neurochemical disruption, prioritizing effective management of confusion.
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