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 D

Explanation

A. While medications like SSRIs (Selective Serotonin Reuptake Inhibitors) or benzodiazepines may eventually be part of the treatment plan for OCD, administering medication should not be the first action unless the client is in acute distress or experiencing severe anxiety symptoms that require immediate pharmacological intervention.
B. This option involves assessing the severity of anxiety symptoms, which is important for understanding the client's baseline anxiety level. However, calculating this score is not the first action. It can be done later as part of the comprehensive assessment to guide ongoing treatment planning.
C. Relaxation exercises, such as deep breathing or progressive muscle relaxation, can help manage anxiety symptoms in clients with OCD. However, before initiating specific interventions like relaxation exercises, the nurse should first establish rapport, assess the client's current level of distress, and gather information about the client's symptoms and coping mechanisms.
D. Response prevention is a cognitive-behavioral therapy technique used in the treatment of OCD, where clients are prevented from engaging in compulsive behaviors. This should follow after thorough assessment of the actual psychological state of the client.

A. Repeat orientation questions until the client gives a correct response. B. Make a personal introduction to the client at each interaction. C. Give the client a list of foods to choose from for dinner. D. Provide the client with a dark environment for sleeping.

Correct Answer is B

Explanation

A. It is not effective to repeatedly ask orientation questions to a client with dementia. Dementia causes progressive memory loss and cognitive decline, and the client may not be able to provide the correct response even with repeated questioning. This approach can lead to frustration and agitation for the client.
B. Introducing oneself at each interaction is a good practice because individuals with dementia may have difficulty remembering people or recognizing familiar faces. It helps establish rapport and reduces confusion or anxiety that may arise from not recognizing caregivers or staff.
C. Providing choices can help empower the client and maintain some level of independence in decision- making. However, it's important to keep the choices limited and clear, as too many options can overwhelm and confuse a person with dementia. Additionally, offering familiar and preferred foods can enhance the client's comfort and enjoyment of meals.
D. Providing a dark environment for sleeping may not be appropriate for all clients with dementia. Some individuals may become disoriented or agitated in complete darkness. It's generally recommended to provide a quiet and calm environment with subdued lighting during nighttime hours to support restful sleep.

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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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