A woman in a severely abusive relationship is hospitalized with severe injuries and head trauma. Her husband sends flowers to the unit and a card begging for forgiveness. The nurse recognizes this to be which phase in an abusive relationship?

Phase IV: The Forgiveness Phase

Phase III: The Honeymoon Phase

Phase II: The Acute Battering Incident

Phase I: The Tension-Building Phase

Answer and Explanation

The Correct Answer is B

B. The honeymoon phase occurs after the acute battering incident and is characterized by the abuser showing remorse, apologizing, and trying to reconcile with the victim. During this phase, the abuser may express love, affection, and promises to change.
A. This phase is not typically recognized as a distinct phase in the cycle of abuse.
C. The acute battering incident is the phase characterized by the actual physical or emotional abuse. It is the culmination of tension that has been building in the relationship, leading to an explosive and violent incident.
D. The tension-building phase is the initial phase in the cycle of abuse, characterized by increasing tension and conflict between the partners. During this phase, the victim may try to placate the abuser, avoid conflict, or walk on eggshells to prevent escalation.

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Correct Answer is A

Explanation

A. Ginkgo biloba has been reported to have anticoagulant properties and may potentiate the effects of warfarin, increasing the risk of bleeding. Therefore, individuals taking warfarin should exercise caution when using ginkgo supplements and be monitored closely for signs of bleeding or changes in anticoagulant response.
B. Dandelion is not known to directly affect blood clotting or the action of warfarin.
C. Acai berry is a fruit commonly consumed for its potential antioxidant properties and health benefits. There is limited scientific evidence regarding the interaction between acai and warfarin.
D. Zinc supplementation is generally considered safe for most individuals and there is limited evidence to suggest that zinc significantly enhances the anticoagulant effects of warfarin.

A. Orient the client and offer reassurance B. Encourage the client to drink some fluids C. Orient the client and monitor vital signs D. Assist the client from the stretcher to a wheelchair

Correct Answer is C

Explanation

C. After ECT, the client may be disoriented, confused, or drowsy due to the effects of anesthesia and the procedure itself. Orienting the client to their surroundings and situation helps promote their safety and comfort. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is crucial to assess the client's immediate post-procedural status and detect any complications.
A. Offering reassurance can help alleviate any anxiety or confusion the client may experience. However, while this intervention is important, it may not be the first priority immediately upon admission to the Post Anesthesia Care Unit (PACU).
B. Hydration is important after any medical procedure, including ECT. However, immediately after ECT, the client may still be recovering from anesthesia and may not be fully alert or able to safely drink fluids.
D. Assisting the client with mobility is important but it may not be the first intervention performed in the PACU after ECT. The priority immediately upon admission to the PACU is to ensure the client's safety.

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A woman in a severely abusive relationship is hospitalized with severe injuries and head trauma. Her husband sends flowers to the unit and a card begging for forgiveness. The nurse recognizes this to be which phase in an abusive relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who takes warfarin 10 mg PO daily and several herbal remedies. The nurse would be most concerned that the use of which herb would enhance the anticoagulant effects of warfarin?

Correct Answer is A

Explanation

A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

Correct Answer is C

Explanation

A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

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