A nurse in the emergency department is preparing to care for a ...

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A nurse in the emergency department is preparing to care for a female client who has just been sexually assaulted. Which of the following client behaviors would demonstrate denial?
 
  1. The client is calm and quiet.
  2. The client is blaming her sister for the incident.
  3. The client is justifying unacceptable self-behaviors.
  4. The client is verbalizing generalizations about the incident.

Question 2

The nurse is providing instructions to the parents of an infant with a ventriculoperitonea l shunt. The nurse includes which of the following instructions?
 
  1. Call the physician if the infant is fussy.
  2. Expect an increased urine output from the shunt.
  3. Call the physician if the infant has a high-pitched cry.
  4. Position the infant on the side of the shunt when the infant is put to bed.

[ansleighelindsey]

Answer to Question 1

1

Rationale: Denial is a response by a victim of sexual abuse. It is described as an adaptive and protective reaction and may be identified by a calm and quiet behavior in the client. Projection is blaming, or scapegoating. Rationalization is justifying the unacceptable attributes about self. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.

Answer to Question 2

3

Rationale: If the shunt is malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitou-rinary system, and an increased urinary output is not expected. Call the physician if the infant is fussy is a concern only if other signs indicative of a complication are occurring.

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Gracias!

[miss_1456@hotmail.com]

TYSM