A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?

"I can encourage my child to think about what they did that allowed this event to happen."

"I should encourage my child to focus solely on the future."

"I will have to do all I can to monitor my child's relationships."

"I anticipate that my child will feel some self-blame."

Answer and Explanation

The Correct Answer is D

A.   This statement suggests a potential for victim-blaming or placing responsibility on the adolescent for the assault. It does not reflect a positive support system because it may contribute to feelings of guilt and shame in the adolescent. Victims of sexual assault should not be made to feel responsible for the actions of the perpetrator.
B.   While encouraging the adolescent to focus on the future can be positive, solely focusing on the future without acknowledging or processing the trauma of the assault may invalidate the adolescent's current feelings and experiences. A supportive approach involves acknowledging and validating the adolescent's emotions and experiences, both past and present.
C.   This statement may come from a place of concern for the adolescent's safety and well-being, which is understandable. However, it can also indicate a lack of trust or an overprotective stance that may not fully empower the adolescent to regain a sense of control over their life and decisions.
D.   This statement demonstrates an understanding of common reactions and emotions experienced by individuals who have been sexually assaulted. Acknowledging that the adolescent may feel self-blame can be a way to open up discussions about these feelings and reassure the adolescent that they are not at fault. It shows empathy and readiness to support the adolescent emotionally.

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Correct Answer is ["A","C","E"]

Explanation

A. Incoordination, such as clumsiness or difficulty walking, can be an early sign of lithium toxicity. It reflects the neurological effects of elevated lithium levels on motor coordination.
B. Polyuria (excessive urination) is a common late symptom of lithium toxicity. Lithium interferes with the kidney's ability to concentrate urine, leading to increased urine output.
C. Nausea is a gastrointestinal symptom that can occur in the early stages of lithium toxicity. It is often accompanied by other gastrointestinal disturbances such as vomiting and diarrhea.
D. Convulsions (seizures) are not typically considered early manifestations of lithium toxicity but rather indicate severe toxicity. Seizures can occur at higher levels of lithium toxicity and require immediate medical intervention.
E. Confusion is another early sign of lithium toxicity. It reflects the impact of elevated lithium levels on the central nervous system, leading to cognitive impairment and altered mental status.

A. "Can you see these spiders crawling all over me?" B. "The aliens are going to abduct me tonight." C. "The voices told me to quit eating the food” D. "Are you planning to kill me?"

Correct Answer is C

Explanation

A. This statement describes a visual hallucination (seeing spiders crawling), not a command hallucination. Visual hallucinations involve seeing things that are not actually present.

B. This statement reflects a delusion rather than a hallucination. Delusions are false beliefs that are firmly held despite evidence to the contrary. In this case, the belief in aliens and abduction is not related to hearing voices commanding actions.
C. This statement indicates a command hallucination. The client hears voices instructing them to stop eating. Command hallucinations often involve direct, imperative commands from voices that are perceived as real.
D. This statement reflects paranoia or fear of harm from others, which can be a common symptom in schizophrenia. However, it does not directly indicate a command hallucination.

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A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?

Correct Answer is C

Explanation

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A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

A nurse is assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?

A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?