A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response.
Your friends will understand when you tell them."
"Are you thinking of suicide?"
"It will take time, but you will feel the same as before."
You will be able to find meaning in this experience as time goes on
The Correct Answer is B
A. "Your friends will understand when you tell them." This response, while well-meaning, may minimize the victim's feelings and pressure them to disclose something they might not be ready to share. It does not directly address the immediate emotional crisis the victim is experiencing.
B. "Are you thinking of suicide?" This is the most important response, as it directly addresses the risk of self-harm or suicide, which is a critical concern for victims of violent trauma, especially after a violent assault. The victim's statement, "There is no sense of trying to go on," may indicate feelings of hopelessness or despair, which are warning signs for suicidal ideation. It is essential to assess for any thoughts of suicide immediately to ensure the patient's safety.
C. "It will take time, but you will feel the same as before." While this response is intended to provide reassurance, it is unrealistic and does not acknowledge the trauma and emotional distress the victim is experiencing. Recovery from such an event is complex and often involves long-term emotional and psychological adjustments.
D. "You will be able to find meaning in this experience as time goes on." This response may sound dismissive and may not resonate with the victim at this time. Finding meaning can be part of the healing process later, but this statement may feel like an oversimplification or invalidation of the victim's current emotions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Physical or chemical means or device that restricts client's freedom to and ability to move about is the most accurate definition of restraint. This includes any method or device used to prevent a patient from moving freely, such as physical devices (like straps or handcuffs) or chemical restraints (medications used to sedate or calm the patient).
B. The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving refers to seclusion, not restraints. Seclusion is a form of isolation, often used when a patient is a danger to themselves or others, but it is distinct from restraints.
C. Pharmacological interventions for management of acute behavioral emergencies refers to the use of medication, but this is not specifically a restraint. Restraints involve preventing movement or controlling behavior through either physical or chemical means, but this definition is more about the use of medication in emergencies rather than restricting movement.
D. Safety measures to prevent a threatened or attempted suicide or some serious bodily injury describes precautionary measures rather than the definition of restraint itself. Restraints are about restricting movement, not necessarily about preventing injury or harm directly.
Correct Answer is C
Explanation
A. Lewy body disease is a progressive neurological disorder that affects cognition, movement, and behavior. However, it is primarily characterized by symptoms like visual hallucinations, fluctuating cognitive abilities, and Parkinsonism, not primarily uncontrolled movements as in Huntington's disease.
B. Traumatic brain injury (TBI) refers to damage to the brain due to external physical force, such as from a fall or accident. While TBI can lead to cognitive and emotional changes, it does not cause the uncontrolled movements seen in Huntington's disease.
C. Huntington chorea is a progressive brain disorder caused by a genetic mutation. It is characterized by uncontrolled movements (chorea), emotional problems, and cognitive dysfunction. It primarily affects movement, mood, and cognitive function over time.
D. Alzheimer's disease is a progressive neurodegenerative disease primarily characterized by memory loss, confusion, and cognitive decline. It does not typically cause uncontrolled movements like those seen in Huntington's disease.
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