The mental health nurse is developing a plan of care for a victim ...

[ashley]

The mental health nurse is developing a plan of care for a victim of sexual assault. Which nursing diagnoses are likely appropriate for this client? (Select all that apply.)
 
  A) Anxiety
  B) Impaired verbal communication
  C) Noncompliance
  D) Risk for injury
  E) Deficient knowledge

Question 2

A 38-year-old man has just received word that his latest computed tomography (CT) scan of his head indicates an inoperable brain tumor that is associated with an exceptionally poor prognosis. The man has confided to the nurse,
 
  I think that this is punishment for being unfaithful to my wife, and she doesn't even know that. The nurse would recognize a possible deficit in which of the balancing factors affecting the client's crisis response?
 
  A) Realistic perception of the event
  B) Adequate situational support
  C) Adequate defense or coping mechanisms
  D) Experience with similar situations

[tmlewis4706]

Answer to Question 1

Ans: A, B, D
Nursing diagnoses related to care of the client who has experienced a sexual assault would include anxiety, impaired verbal communication, and risk for injury.

Answer to Question 2

Ans: A
The interpretation of a medical diagnosis as punishment by a higher power may signal an unrealistic perception of the crisis, potentially affecting the individual's ability to respond. The client's statement does not suggest a lack of support or impaired coping strategies. While the client likely has little experience with similar situations, this is not the focus of his statement.