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A client who has been diagnosed as having bulimia nervosa is hospitalized for treatment of electrolyte imbalance. Just before lunch is finished, the client leaves the table and walks quickly in the direction of the bathroom. The nurse should say:
- A. No one is allowed to leave the dining room during meals.'
- B. I must accompany you when you go to the bathroom.'
- C. I think I understand your plan, and I cannot permit you to carry it out.'
- D. Wouldn't it be preferable to exercise rather than vomit?'
Correct Answer: B
Rationale: The correct answer is B because accompanying the client to the bathroom is essential to prevent purging behavior associated with bulimia nervosa. By doing so, the nurse can provide support, monitor the client, and intervene if necessary to ensure the client's safety. Choice A is incorrect as it may come across as punitive and restrictive. Choice C is incorrect as it may escalate the situation and lead to confrontation. Choice D is incorrect as it suggests an alternative behavior without addressing the immediate concern of potential purging. Accompanying the client to the bathroom is the most appropriate and therapeutic response in this situation.
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A psychiatric clinical nurse specialist uses cognitive therapy with a patient with anorexia nervosa. Which statement by the nurse supports this type of therapy?
- A. What are your feelings about not eating foods you prepare?
- B. You seem to feel much better about yourself when you eat something.
- C. It must be difficult to talk about private matters to someone you just met.
- D. Being thin doesn't seem to solve problems. You're thin now but still unhappy.
Correct Answer: D
Rationale: The correct answer is D because it reflects a key principle of cognitive therapy, which is challenging distorted thoughts and beliefs. In this statement, the nurse is helping the patient recognize that being thin has not resolved their underlying unhappiness. This challenges the patient's belief that thinness equals happiness, promoting insight and cognitive restructuring.
A: This statement focuses on emotions related to food and preparation, not directly challenging distorted thoughts.
B: This statement focuses on self-esteem related to eating, not directly challenging distorted thoughts.
C: This statement addresses the difficulty of sharing personal information, not directly challenging distorted thoughts.
Which complication should a nurse monitor for when treating a patient with bulimia nervosa who is experiencing frequent vomiting?
- A. Hypokalemia and dental enamel erosion.
- B. Hyperkalemia and elevated blood pressure.
- C. Severe dehydration and low blood sugar.
- D. Hypercalcemia and weight gain.
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia and dental enamel erosion.
1. Bulimia nervosa involves frequent vomiting, leading to loss of potassium (hypokalemia) due to electrolyte imbalance.
2. Vomiting also damages tooth enamel, causing dental erosion.
3. Hyperkalemia and elevated blood pressure (choice B) are not typically associated with bulimia.
4. Severe dehydration and low blood sugar (choice C) are possible but not the primary concerns.
5. Hypercalcemia and weight gain (choice D) are not common complications of bulimia.
It is a secondary dementia indicated by loss of recent memory and disorientation to time and place.
- A. Alzheimer's disease.
- B. Vascular dementia.
- C. Lewy body dementia.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Alzheimer's disease. Alzheimer's disease is a common type of dementia characterized by progressive cognitive decline, including loss of recent memory and disorientation to time and place. This is due to the accumulation of amyloid plaques and neurofibrillary tangles in the brain. Vascular dementia (B) is caused by reduced blood flow to the brain, leading to cognitive impairment. Lewy body dementia (C) is characterized by the presence of abnormal protein deposits called Lewy bodies in the brain. Choosing D (None of the above) would be incorrect as Alzheimer's disease specifically matches the description provided in the question.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
Priority nursing interventions for a client with borderline personality disorder who has a history of self-mutilation and is currently angry, irritable, and impulsive would be:
- A. Establishing a contract for safety with the client
- B. Teaching the client ways to manage anger
- C. Helping the client tolerate feelings
- D. Implementing behavioral modification
Correct Answer: A
Rationale: The correct answer is A: Establishing a contract for safety with the client. This is the priority intervention as it focuses on ensuring the client's immediate safety. By setting up a contract for safety, the nurse can collaborate with the client on identifying warning signs and developing a plan to prevent self-harm.
Choice B (Teaching the client ways to manage anger) and Choice C (Helping the client tolerate feelings) are important interventions but may not be as urgent as ensuring the client's safety in this scenario.
Choice D (Implementing behavioral modification) is not the priority because the client's safety needs to be addressed first before focusing on behavioral changes.