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Practice Questions 4

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Total Questions : 5

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Question 1:

The nurse is assessing a client 3 weeks after a sexual assault who reports intrusive memories, nightmares, avoidance of reminders, and marked hyperarousal. Which of the following diagnoses is most consistent with the client's symptoms?

A. Major depressive disorder B. Posttraumatic stress disorder C. Adjustment disorder with anxiety D. Acute stress disorder

Answer and Explanation

Choice A:

Major depressive disorder centres on anhedonia and persistent low mood for at least 2 weeks. Intrusion and avoidance are not criteria. No mood or neurovegetative symptoms are reported. The cluster does not fit.

Choice B:

Intrusion with avoidance and hyperarousal reproduces the full symptom architecture of posttraumatic stress disorder. Nightmares and intrusive memories represent reexperiencing. Avoidance of reminders prevents extinction learning. This cluster combination is diagnostically specific.

Choice C:

Adjustment disorder follows a non-traumatic stressor with disproportionate emotional response. Criterion A traumatic exposure excludes it here. Intrusion and hyperarousal clusters are absent from its criteria. It is a diagnosis of exclusion.

Choice D:

Acute stress disorder shares the symptom content but differs in required timeframe. It applies only within the first month. The clusters described match the trauma spectrum broadly. Duration is the discriminating variable.

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Question 2:

The nurse is evaluating a client who experienced sexual assault and now reports persistent sadness, anhedonia, and passive suicidal ideation without a plan. Which of the following nursing actions should the nurse take first?

A. Schedule a routine follow-up appointment with the primary health care provider in 2 weeks. B. Provide written information about local mental health resources and crisis lines. C. Ask the client directly about suicidal thoughts and whether they have a plan or intent. D. Encourage the client to attend a community support group for survivors.

Answer and Explanation

Choice A:

Two-week follow-up leaves an unassessed interval during which risk may escalate. Passive ideation warrants same-day evaluation. Routine scheduling assumes stability not yet established. The delay is unsafe.

Choice B:

Written resources support self-directed help-seeking at a later time. Printed material provides no immediate risk stratification. Utilization depends on client initiative. Distribution follows assessment.

Choice C:

Direct questioning about plan and intent stratifies acute lethality and determines the required level of care. Passive ideation can escalate without warning. Evidence confirms asking does not plant the idea. Assessment precedes every intervention.

Choice D:

Support group referral offers peer validation over successive sessions. Participation presupposes established safety. Benefit accrues gradually rather than immediately. It cannot precede risk evaluation.

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Question 3:

The nurse is reviewing prophylactic medical management options with a client who presents within 72 hours after a sexual assault. Which of the following interventions are commonly offered as part of immediate prophylaxis? Select all that apply.

A. Hepatitis B vaccination series if the client is not immune B. Initiation of daily oral zidovudine for immediate HIV cure C. Emergency contraception to reduce risk of pregnancy D. Empiric oral azithromycin for chlamydia prophylaxis E. Single-dose intramuscular ceftriaxone for gonorrhea prophylaxis

Answer and Explanation

Choice A:

Hepatitis B vaccination is initiated when the client lacks documented immunity, with immune globulin added for known positive assailants. The series continues at 1 and 6 months. Post-exposure vaccination is highly effective. Serologic status guides the decision.

Choice B:

Zidovudine monotherapy cannot cure human immunodeficiency virus, and prophylaxis requires 3 agents for 28 days. Modern regimens favour tenofovir-based combinations. Monotherapy promotes resistance. The premise is doubly incorrect.

Choice C:

Emergency contraception prevents ovulation and reduces pregnancy risk after unprotected exposure. Levonorgestrel acts within 72 hours; ulipristal extends to 120 hours. A pre-existing pregnancy must be excluded. Efficacy declines with delay.

Choice D:

Azithromycin has been superseded by doxycycline for chlamydia in current treatment guidelines. Doxycycline demonstrates superior efficacy, particularly for rectal infection. Azithromycin remains an alternative only. It is not the standard regimen.

Choice E:

Immediate prophylaxis covers pregnancy, gonorrhea, chlamydia, trichomoniasis, and hepatitis B. Human immunodeficiency virus prophylaxis uses a 3-drug regimen for 28 days, and prevents rather than cures infection.

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Question 4:

The nurse is planning care for a client who reports heavy alcohol use and was sexually assaulted. Which of the following interventions should the nurse prioritize initially?

A. Offer written resources about harm reduction and local mutual-help groups. B. Encourage the client to sign a safety plan and identify sober supports. C. Assess the client for signs of acute alcohol withdrawal and obtain vital signs. D. Provide education about community substance use treatment programs.

Answer and Explanation

Choice A:

Written harm reduction resources support long-term risk reduction and community linkage. Printed material addresses no acute physiological threat. Utilization requires later readiness. It cannot be the initial action.

Choice B:

Safety plan signing with sober supports promotes relapse prevention and ongoing protection. The intervention presumes physiological stability. Withdrawal-related confusion undermines participation. Assessment must come first.

Choice C:

Withdrawal assessment with vital signs detects autonomic hyperactivity signalling impending seizure or delirium tremens. Tachycardia, hypertension, tremor, and fever are objective markers. Benzodiazepine prophylaxis depends on these data. Physiological risk precedes all planning.

Choice D:

Treatment program education belongs to the implementation phase after stabilization. Motivation and readiness determine uptake. Teaching during withdrawal is poorly retained. It addresses no immediate danger.

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Question 5:

The nurse is using therapeutic communication during an acute crisis intervention with a client who experienced sexual assault and expresses feelings of shame and self-blame. Which of the following responses by the nurse are appropriate? Select all that apply.

A. "Many survivors feel confused and blame themselves; that reaction is common." B. "You should try to forget about it and move on quickly." C. "Would you like me to help you contact an advocate or crisis counselor now?" D. "You are to blame for what happened because you were in that situation." E. "I believe you, and I am here to support you through this."

Answer and Explanation

Choice A:

Normalizing self-blame as a common reaction reduces isolation without endorsing the belief. Universality counters the sense of personal defect. Psychoeducation corrects misattribution of responsibility. Shame diminishes as understanding grows.

Choice B:

Advising the client to forget and move on minimizes distress and promotes avoidance coping. Suppression blocks emotional processing and extinction learning. The response invalidates present suffering. Recovery timelines cannot be dictated.

Choice C:

Offering facilitated referral preserves client choice while providing active coordination. Acute stress impairs the executive function needed to initiate contact. Asking rather than imposing restores control. Uptake improves substantially with facilitation.

Choice D:

Assigning blame to the client constitutes overt victim-blaming and secondary victimization. Responsibility rests entirely with the perpetrator. Such statements intensify shame and suicidality. The response is professionally indefensible.

Choice E:

Explicit belief with offered presence counters the fear of disbelief that suppresses disclosure. Affirmation establishes therapeutic trust immediately. Support is stated rather than assumed. This is foundational crisis communication.

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Practice Questions 4

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