which of the following clients is at the highest risk of becoming a victim of intimate partner violence
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX Questions Quizlet

1. Which of the following individuals is at the highest risk of experiencing intimate partner violence?

Correct answer: A 20-year-old woman who grew up with a psychologically abusive father

Rationale: Intimate partner violence is a serious issue encompassing physical, psychological, or sexual abuse within an intimate relationship. Individuals who have experienced psychological abuse in their upbringing are at a higher risk of becoming victims themselves due to the normalization of abusive behaviors. While factors such as age, mental health conditions, and social support can contribute to vulnerability, growing up in an abusive environment can significantly heighten the risk of intimate partner violence. The other options, such as recent divorce (A), unemployment (B), and schizophrenia diagnosis (D), do not directly correlate with the same level of increased risk associated with a history of psychological abuse.

2. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

Correct answer: Safety

Rationale: In caring for a client with severe depression, ensuring safety is a top priority. Suicide prevention measures must be incorporated into the care plan as individuals with depression are at increased risk. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the critical need to prevent harm or self-harm in depressed individuals.

3. When caring for a patient who speaks a different language and an interpreter is unavailable, which action by the nurse is most appropriate?

Correct answer: D: Use simple gestures to demonstrate meaning while communicating

Rationale: When faced with a language barrier and lacking an interpreter, using simple gestures can help convey meaning to the patient. This approach can assist in basic communication and understanding. Talking slowly may not be effective if the patient does not understand the language, and speaking loudly can be perceived as aggressive or intimidating. Repeating words may not aid comprehension if the patient is unfamiliar with the language. Therefore, using gestures is the most appropriate option in this situation.

4. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?

Correct answer: Electrolytes

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

5. After undergoing dilation and curettage following an early miscarriage, a client is crying. Which response would the nurse give?

Correct answer: ''This must be a very difficult experience for you to deal with.''

Rationale: The correct response acknowledges the client's grief without judgment and provides validation. Choice B is inappropriate as it suggests replacing the lost child with other children, which is insensitive and dismissive of the client's current loss. Choice C minimizes the client's feelings by focusing on the ability to get pregnant rather than addressing the emotional impact of the miscarriage. Choice D is dismissive and patronizing, suggesting that the miscarriage was for the best, which can be hurtful and diminish the client's grief.

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When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?
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