Question

Select which statement about ANGER is true.

Answer 1

Correct Answers:

Anger results from being frustrated, hurt, or afraid.

Rationale :

💠 Anger is a normal human emotion that often arises as a secondary response to underlying feelings such as frustration, hurt, fear, or perceived injustice.

💠 Recognizing these root emotions is essential for managing anger in a healthy and constructive way.

💠 Open and direct expression of anger, when done therapeutically, does not always lead to arguments; it can promote understanding if communicated appropriately.

💠 Suppressing anger is not a sign of maturity; instead, it can lead to resentment, stress, or eventual explosive outbursts.

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Answer 2

Correct Answers:

"I should call the provider if I experience excessive sweating and muscle twitching."

Rationale :

💠 Sertraline is a Selective Serotonin Reuptake Inhibitor (SSRI) used to treat post-traumatic stress disorder (PTSD) by increasing serotonin levels in the brain.

💠 Excessive sweating, muscle twitching, confusion, and agitation can indicate serotonin syndrome, a potentially life-threatening condition that requires immediate medical attention.

💠 Dry cough and changes in taste or smell are not typical adverse effects of sertraline, and sodium intake adjustments are not necessary (though hyponatremia can rarely occur, it is not diet-related).

💠 Teaching clients to monitor for serotonin syndrome symptoms ensures early detection and prompt intervention.

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Answer 3

Correct Answers:

Is there a safe place to go if you need to?
Do you have children and are they safe?
Are you concerned about your safety?

Rationale :

Is there a safe place to go if you need to?

🟢 This question is appropriate and therapeutic because it focuses on safety planning without being judgmental or confrontational.

🟢 It allows the nurse to assess whether the patient has an escape plan or access to emergency resources, which is critical in suspected intimate partner violence (IPV) or abuse cases.

🟢 Asking about a safe place also empowers the patient to consider options for protection while maintaining autonomy and control over her decisions.

🟢 It reflects trauma-informed care principles by being supportive, non-threatening, and focused on immediate safety needs.

Do you have children and are they safe?

🟢 Assessing for the presence and safety of children is crucial because abuse in the home often places children at risk for physical or emotional harm.

🟢 This question is appropriate, as healthcare providers are mandated reporters in many jurisdictions when child abuse or neglect is suspected.

🟢 It also helps the nurse determine whether additional resources, such as child protective services or family support services, need to be involved.

🟢 Asking in a calm, supportive tone encourages the patient to share information without feeling blamed or pressured.

Are you concerned about your safety?

🟢 This is a direct yet nonjudgmental way to assess the patient’s level of risk and perception of her situation.

🟢 It allows the patient to express fear or concern about ongoing abuse, which is an essential step in determining immediate interventions or referral to appropriate services.

🟢 Asking about her own perception of safety respects her autonomy and avoids imposing assumptions, which is key in building trust.

🟢 It also opens the door for further discussion about available resources, such as shelters, advocacy programs, or law enforcement assistance.

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Answer 4

Correct Answers:

Assess for risk of immediate harm to patient or children

Rationale :

🟢 Priority nursing action always follows the ABCs and Maslow’s hierarchy, with safety as the top priority. Determining whether the patient or children are at immediate risk of serious injury or death is critical to guide urgent interventions.

🟢 This includes asking direct but supportive questions such as: "Are you afraid to go home?" or "Has the violence gotten worse recently?"

🟢 If there is an imminent threat, emergency services, legal protection (e.g., restraining orders), or hospitalization may need to be arranged immediately.

🟢 Identifying the level of danger also informs the urgency of implementing other interventions, such as safety planning and involving protective services.

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Answer 5

Correct Answers:

The client puts the number of the crisis center into their phone.

Rationale :

💎 Actively putting the crisis center number into their phone shows that the client is engaging with the safety plan and is prepared to use available resources if needed.

💎 This action demonstrates readiness and acceptance of the safety planning process, indicating the client is taking concrete steps toward ensuring personal safety.

💎 The other options do not reflect active participation: not planning to leave shows resistance to change, believing the baby makes the home safer reflects denial, and thanking the nurse is polite but does not confirm behavioral follow-through.

💎 Behavioral evidence, such as saving the crisis number, is a more reliable indicator of whether the safety plan has been understood and integrated.

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Answer 6

Correct Answers:

3

Rationale :

🧮 Calculation:

📌 Desired dose ÷ Available dose = Number of tablets

📌 7.5 mg ÷ 2.5 mg/tablet = 3 tablets

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Answer 7

Correct Answers:

Provide the client with information on resources in the community to support victims of violence.

Rationale :

💎 The most therapeutic and appropriate nursing action for victims of intimate partner violence (IPV) is to provide information on community resources such as shelters, crisis hotlines, counseling services, and legal advocacy.

💎 This empowers the client to make informed decisions about their safety and future while respecting their autonomy.

💎 Suggesting ways to avoid making the partner angry implies victim-blaming and reinforces the cycle of abuse, which is unethical and non-therapeutic.

💎 Providing strategies for social interactions does not address the immediate needs for safety and support that IPV victims require.

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Answer 8

Correct Answers:

Follow the agency's guidelines for reporting suspected abuse.

Rationale :

💎 Suspected elder abuse must be reported immediately as mandated by law in most jurisdictions, regardless of whether there is definitive proof.

💎 Following the agency’s guidelines for reporting ensures that the appropriate authorities or protective services are notified to investigate and ensure the client’s immediate safety.

💎 Delaying action , increasing visit frequency , or arranging family therapy does not address the urgent safety risk and may place the client at continued risk of harm.

💎 Nurses are mandatory reporters, and client safety always takes priority over maintaining family harmony.

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Answer 9

Correct Answers:

The client has anal bleeding.
The client complains of pelvic soreness.
The client has bruises around the breasts.
The client's underwear is bloody.

Rationale :

The client has anal bleeding

🟢 Anal bleeding is a significant and concerning physical finding that strongly correlates with forced anal penetration, which is common in some cases of sexual abuse.

🟢 The bleeding may result from tears, abrasions, or lacerations of the anal mucosa caused by trauma.

🟢 This finding, when associated with the client’s report and without another medical explanation (such as hemorrhoids), is highly consistent with sexual assault.

🟢 Proper forensic documentation, including photographs and description of the bleeding, is critical for legal and medical purposes.

The client complains of pelvic soreness

🟢 Pelvic or genital soreness is a frequent subjective symptom following sexual abuse due to muscle strain, bruising, or internal trauma from forced vaginal penetration.

🟢 This symptom, even in the absence of visible external trauma, should be taken seriously, as many soft tissue injuries are not immediately apparent.

🟢 Pelvic soreness should prompt a gentle, trauma-informed physical examination to evaluate for internal injuries or swelling.

🟢 Documentation of subjective complaints is just as important as physical findings in building a consistent clinical and forensic picture.

The client has bruises around the breasts

🟢 Bruising on the breasts is a common physical finding in sexual abuse, caused by grabbing, squeezing, or forceful restraint during the assault.

🟢 These bruises are often accompanied by other injuries to the upper arms or inner thighs, reflecting the use of physical force.

🟢 The nurse should carefully measure and document the size, color, and location of the bruises, as they are significant forensic evidence.

🟢 The presence of bruising in sensitive or private areas is a strong indicator of non-consensual physical contact.

The client’s underwear is bloody

🟢 Blood-stained undergarments are highly suggestive of genital or rectal trauma caused by penetration.

🟢 This finding should be handled as forensic evidence, meaning the underwear must not be washed or handled excessively and should be placed in a paper evidence bag to preserve DNA.

🟢 The presence of blood supports the client’s report of abuse and provides crucial physical corroboration for investigators.

🟢 This finding highlights the need for a forensic sexual assault examination (rape kit) to collect biological evidence promptly.

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Answer 10

Correct Answers:

Determine the client's level of anxiety

Rationale :

💎 In obsessive-compulsive disorder (OCD), compulsive behaviors are performed to reduce anxiety caused by persistent and intrusive obsessive thoughts.

💎 Assessing the client’s level of anxiety is essential because interventions are most effective when tailored to the severity of the anxiety.

💎 High anxiety may require allowing the client to initially perform rituals while gradually introducing strategies such as relaxation techniques and cognitive-behavioral therapy (CBT).

💎 Interrupting compulsive behavior or using negative reinforcement can increase anxiety and worsen the compulsions, and avoiding anxiety-inducing situations is counterproductive, as exposure therapy is often part of treatment.

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QLexNursing

1 :
Select which statement about ANGER is true.

2 :
A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

3 :
A woman is slowly walking into the ED with her head down and whispers her name at the desk to the nurse.

Answer Options

4 :
A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

6 :
A nurse is preparing to administer olanzapine 7.5 mg PO to a client who has schizophrenia. Available is olanzapine 2.5 mg tablets. How many tablets should the nurse plan to administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

7 :
A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?

9 :
A nurse in the emergency department is caring for a client who reports having experienced sexual abuse. The nurse should identify which of the following findings are consistent with the client's report?
(Select All that Apply.)

10 :
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?

QLexNursing

1 : Select which statement about ANGER is true.

2 : A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

3 : A woman is slowly walking into the ED with her head down and whispers her name at the desk to the nurse.

Answer Options

4 : A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

6 : A nurse is preparing to administer olanzapine 7.5 mg PO to a client who has schizophrenia. Available is olanzapine 2.5 mg tablets. How many tablets should the nurse plan to administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

7 : A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?

9 : A nurse in the emergency department is caring for a client who reports having experienced sexual abuse. The nurse should identify which of the following findings are consistent with the client's report?(Select All that Apply.)

10 : A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?

1 :
Select which statement about ANGER is true.

2 :
A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

3 :
A woman is slowly walking into the ED with her head down and whispers her name at the desk to the nurse.

4 :
A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

6 :
A nurse is preparing to administer olanzapine 7.5 mg PO to a client who has schizophrenia. Available is olanzapine 2.5 mg tablets. How many tablets should the nurse plan to administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

7 :
A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?

9 :
A nurse in the emergency department is caring for a client who reports having experienced sexual abuse. The nurse should identify which of the following findings are consistent with the client's report?
(Select All that Apply.)

10 :
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?