Question

The nurse should most suspect which of the following when presented with an older, mentally impaired woman who is depressed and underweight and has poor personal hygiene?

Answer 1

Correct Answers:

Neglect

Rationale :

🔷 Neglect is the most likely cause when an older adult presents with poor personal hygiene, weight loss, and depression, especially if she is mentally impaired and dependent on others for care.

🔷 It involves the failure of a caregiver to provide basic needs, including proper nutrition, hygiene, medical care, and emotional support.

🔷 Depression and underweight status are strong indicators that the individual’s physical and emotional needs are not being adequately met.

🔷 Unlike physical abuse (which shows bruises or injuries) or exploitation (which involves financial misuse), neglect primarily manifests as self-care deficits due to caregiver omission.

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Answer 2

Correct Answers:

Apply restraints.

Rationale :

💠 When a client becomes physically aggressive and poses an immediate risk of harm to staff or others, the priority is safety.

💠 Restraints are appropriate as a last-resort intervention when less restrictive measures, such as verbal de-escalation or oral medication, are ineffective or not feasible in the acute situation.

💠 The use of restraints must follow facility policy and legal guidelines, including obtaining a provider’s order, ensuring continuous monitoring, and using the least restrictive type necessary.

💠 This intervention protects both the client and healthcare staff until the client regains control or medication can be administered safely.

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Answer 3

Correct Answers:

Low birth-weight infant

Rationale :

💎 Pregnant women who experience abuse are at high risk for delivering low birth-weight infants due to chronic stress, poor nutrition, and inadequate prenatal care.

💎 Physical trauma and emotional stress can cause placental insufficiency or preterm labor, contributing to intrauterine growth restriction and low birth weight.

💎 Abused women often do not seek or receive consistent prenatal care because of fear, isolation, or control by the abuser, further increasing the risk for adverse pregnancy outcomes.

💎 Recognizing this risk helps nurses prioritize screening for abuse and providing appropriate supportive interventions for both mother and infant.

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Answer 4

Correct Answers:

intermittent explosive disorder

Rationale :

🔶 Intermittent explosive disorder (IED) is characterized by sudden episodes of verbal aggression or physical violence that are out of proportion to the stressor.

🔶 The described behavior—yelling, cursing, and striking a bank teller over a minor frustration—fits the hallmark impulsive and uncontrolled aggressive outburst of IED.

🔶 These episodes are typically brief, and the individual often feels remorse or embarrassment afterward, distinguishing it from chronic behavioral disorders.

🔶 Unlike conduct disorder or oppositional defiant disorder, which are more persistent and usually diagnosed in children or adolescents, IED occurs in adults and involves episodic explosive reactions.

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Answer 5

Correct Answers:

Pyromania

Rationale :

💎 Pyromania is classified as an impulse control disorder characterized by a recurrent, irresistible urge to deliberately set fires for pleasure, gratification, or relief of tension.

💎 Individuals with impulse control disorders have difficulty resisting harmful impulses, even when aware of the negative consequences.

💎 Other examples of impulse control disorders include kleptomania and intermittent explosive disorder, whereas behaviors such as deceitfulness, aggressive conduct, or rule violations are more typical of conduct disorder or antisocial personality disorder.

💎 Recognizing pyromania as an impulse control disorder is important for appropriate psychiatric evaluation and behavioral therapy.

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Answer 6

Correct Answers:

“One should expect hand tremors to start less than 24 hours after I stop drinking."

Rationale :

🔷 Alcohol withdrawal symptoms typically begin 6 to 24 hours after the last drink, with hand tremors (the “shakes”) being one of the earliest and most common signs.

🔷 Other early symptoms include anxiety, diaphoresis, nausea, and irritability, progressing to more severe complications such as seizures or delirium tremens (DTs) if untreated.

🔷 Disulfiram does not reduce cravings; it causes an aversive reaction when alcohol is ingested. Vitamin C does not prevent cirrhosis; instead, thiamine (Vitamin B1) is crucial to prevent Wernicke-Korsakoff syndrome during withdrawal.

🔷 Understanding the timeline of withdrawal symptoms helps ensure early recognition and prompt treatment to prevent complications.

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Answer 7

Correct Answers:

Make a no self-harm contract.

Rationale :

💠 A no self-harm (or no-suicide) contract is a therapeutic agreement where the client verbally or in writing commits to not harming themselves and to seek help if suicidal thoughts intensify.

💠 While not legally binding, it serves as an immediate safety measure and helps establish trust and therapeutic rapport between the nurse and client.

💠 It also opens communication about suicidal ideation and encourages the client to collaborate in their own safety planning.

💠 Other interventions, such as close observation and removal of dangerous objects, are also crucial, but isolating the client or restricting visits can worsen feelings of hopelessness.

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Answer 8

Correct Answers:

Establish and maintain a trusting relationship.

Rationale :

💎 The most therapeutic intervention for managing anger and aggression is building a trusting nurse–client relationship, as it creates a foundation for open communication and de-escalation.

💎 A therapeutic relationship helps the client feel heard, respected, and supported, which can reduce feelings of hostility and frustration.

💎 While setting limits and offering PRN medication are sometimes necessary, they are secondary to establishing trust, which is essential for long-term behavioral control and emotional regulation.

💎 Trust also enhances the client’s willingness to participate in problem-solving and coping strategies, reducing the risk of recurrent aggressive outbursts.

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Answer 9

Correct Answers:

Leave the client's room.

Rationale :

🔷 When a client becomes verbally abusive, the nurse should prioritize maintaining professional boundaries and ensuring safety by leaving the room calmly.

🔷 This action communicates that abusive behavior will not be tolerated while preventing further escalation of aggression.

🔷 Remaining in the room, making judgmental statements, or attempting to punish the client may reinforce or worsen the abusive behavior.

🔷 After leaving, the nurse can return later to reassess the client’s emotional state and attempt therapeutic communication once the client is calm.

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Answer 10

Correct Answers:

Whites

Rationale :

💠 Epidemiological data from substance use surveys indicate that cocaine use is reported at a higher prevalence among White Americans compared to other ethnic groups.

💠 Various factors, including socioeconomic status, availability, and cultural trends, contribute to differences in substance use patterns among populations.

💠 Although African Americans and Hispanic Americans may experience more severe legal and health consequences from cocaine use due to systemic disparities, overall usage rates remain higher among Whites.

💠 Understanding demographic trends in substance use is important for targeted prevention and treatment programs.

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QLexNursing

1 :
The nurse should most suspect which of the following when presented with an older, mentally impaired woman who is depressed and underweight and has poor personal hygiene?

2 :
An out-of-control client is verbally abusive and physically aggressive with staff members who are at increased risk for injury. Which intervention is most appropriate?

3 :
An abused pregnant woman gives birth to a baby girl. The nurse should suspect which of the following?

4 :
A person yells, curses, and strikes a bank teller for making her wait in line too long. This behavior is consistent with which of the following?

5 :
Which of the following is an impulse control disorder?

6 :
A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching?

7 :
An elderly male client is hospitalized immediately after attempting suicide. Which of the following is implemented as a suicide precaution?

8 :
The most therapeutic caregiver intervention for a client with anger and aggression is which of the following?

9 :
A nurse is caring for a client who becomes verbally abusive when the nurse enters her room. Which of the following actions should the nurse take?

10 :
The use of cocaine is higher in which group of people?

QLexNursing

1 : The nurse should most suspect which of the following when presented with an older, mentally impaired woman who is depressed and underweight and has poor personal hygiene?

2 : An out-of-control client is verbally abusive and physically aggressive with staff members who are at increased risk for injury. Which intervention is most appropriate?

3 : An abused pregnant woman gives birth to a baby girl. The nurse should suspect which of the following?

4 : A person yells, curses, and strikes a bank teller for making her wait in line too long. This behavior is consistent with which of the following?

5 : Which of the following is an impulse control disorder?

6 : A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching?

7 : An elderly male client is hospitalized immediately after attempting suicide. Which of the following is implemented as a suicide precaution?

8 : The most therapeutic caregiver intervention for a client with anger and aggression is which of the following?

9 : A nurse is caring for a client who becomes verbally abusive when the nurse enters her room. Which of the following actions should the nurse take?

10 : The use of cocaine is higher in which group of people?

1 :
The nurse should most suspect which of the following when presented with an older, mentally impaired woman who is depressed and underweight and has poor personal hygiene?

2 :
An out-of-control client is verbally abusive and physically aggressive with staff members who are at increased risk for injury. Which intervention is most appropriate?

3 :
An abused pregnant woman gives birth to a baby girl. The nurse should suspect which of the following?

4 :
A person yells, curses, and strikes a bank teller for making her wait in line too long. This behavior is consistent with which of the following?

5 :
Which of the following is an impulse control disorder?

6 :
A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching?

7 :
An elderly male client is hospitalized immediately after attempting suicide. Which of the following is implemented as a suicide precaution?

8 :
The most therapeutic caregiver intervention for a client with anger and aggression is which of the following?

9 :
A nurse is caring for a client who becomes verbally abusive when the nurse enters her room. Which of the following actions should the nurse take?

10 :
The use of cocaine is higher in which group of people?