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A patient with mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Ineffective coping
- C. Ineffective management of therapeutic regime
- D. Imbalanced nutrition
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition. Priority is given to physiological needs. The patient not eating for 3 days can lead to serious health complications. This nursing diagnosis addresses the immediate risk to the patient's physical well-being. Choices A, B, and C are important but addressing the patient's nutritional needs is the priority to prevent further deterioration in their condition.
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Which nursing diagnosis is more relevant for a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges?
- A. Powerlessness
- B. Ineffective coping
- C. Disturbed body image
- D. Imbalanced nutrition: less than body requirements
Correct Answer: D
Rationale: The correct answer is D, Imbalanced nutrition: less than body requirements. For a patient with anorexia nervosa who restricts intake and is 20% below normal weight, this diagnosis is more relevant as it directly addresses the issue of inadequate food intake leading to weight loss. Powerlessness (A) may not be as directly related to the physical consequences of anorexia. Ineffective coping (B) and Disturbed body image (C) are more commonly associated with bulimia nervosa and do not address the primary concern of malnutrition in this case.
Inappropriate, life-threatening or challenging behaviours may be inadvertently maintained by reinforcement from others in the environment. Which of the following is a process that can be carried out in order to help identify the factors maintaining the behaviour?
- A. Functional analysis
- B. Statistical analysis
- C. Behavioural analysis
- D. Procedural analysis
Correct Answer: A
Rationale: Functional Analysis: Using operant conditioning principles to identify rewarding or reinforcing factors maintaining behavior.
True paranoids are rarely treated or admitted to hospitals because
- A. they are potentially harmful and dangerous to others
- B. they resist the attempts of others to offer help
- C. their severe hallucinations make reasoning with them impossible
- D. psychiatric hospitals are primarily for psychotics
Correct Answer: B
Rationale: Paranoid individuals' mistrust leads them to resist help, reducing treatment rates.
The nurse at the clinic is interviewing a patient who offers a number of vague somatic complaints that might not ordinarily prompt a visit to a caregiver: fatigue, back pain, headaches, and sleep disturbance. The patient seems tense, and after having spoken of the symptoms, seems reluctant to provide more information and is in a hurry to leave. The nurse can best serve the patient by:
- A. Asking if the patient has ever had psychiatric counseling.
- B. Completing a structured abuse assessment protocol.
- C. Exploring the possibility of patient social isolation.
- D. Asking the patient to disrobe to check for signs of abuse.
Correct Answer: B
Rationale: The correct answer is B: Completing a structured abuse assessment protocol. Given the patient's vague complaints, tension, reluctance to provide more information, and hurry to leave, these could be signs of potential abuse. Completing a structured abuse assessment protocol allows the nurse to systematically assess for any signs of abuse, which could be contributing to the patient's somatic complaints. This approach is necessary to ensure the patient's safety and well-being.
Incorrect choices:
A: Asking if the patient has ever had psychiatric counseling - This choice does not directly address the potential abuse concerns indicated by the patient's behavior.
C: Exploring the possibility of patient social isolation - While social isolation could be a contributing factor, the urgency to leave and reluctance to provide information are more indicative of potential abuse.
D: Asking the patient to disrobe to check for signs of abuse - This choice is invasive and inappropriate without first completing a structured abuse assessment protocol to determine if abuse is likely.
Which of the following best describes a social gambler
- A. Someone who gambles for the heightened thrill and needs higher bets to achieve the same feeling
- B. Gambles for fun during New Year gatherings
- C. Believes gambling is a way to make money, similar to financial investment
- D. Steals money to feed the gambling habit
Correct Answer: B
Rationale: A social gambler engages in gambling recreationally, such as during social events like New Year gatherings, without dependency.