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Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis?
- A. Weight, muscle, and fat congruence with height, frame, age, and sex.
- B. Calorie intake within required parameters of treatment plan.
- C. Weight at established normal range for the patient.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because disturbed body image in an eating disorder patient involves a discrepancy between their perceived body image and reality. Monitoring weight, muscle, and fat congruence with height, frame, age, and sex helps assess if the patient's perception aligns with their actual physical state. Choice B focuses solely on calorie intake, which does not directly address body image perception. Choice C only considers weight, neglecting the importance of muscle and fat distribution in body image perception. Choice D is incorrect as option A is the most relevant outcome indicator for disturbed body image in this scenario.
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A patient diagnosed with schizophrenia reveals to the nurse that voices have warned of danger and adds, 'They're so loud they frighten me. Do you hear them?' The nurse's best initial response would be:
- A. I know these voices are very real to you, but I don't hear them.'
- B. Don't worry. You're safe in the hospital. I won't let anything happen to you.'
- C. Tell me more about the voices. Are they men or women? How many are there?'
- D. What do you do in order to keep yourself occupied so you don't hear the voices?'
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's experience without dismissing or invalidating it. By stating, "I know these voices are very real to you, but I don't hear them," the nurse validates the patient's reality and expresses empathy. This response helps build trust and rapport, which is crucial in establishing a therapeutic relationship.
Choice B is incorrect because it dismisses the patient's concerns and offers false reassurance, which may not be effective in addressing the patient's distress.
Choice C is incorrect as it focuses on gathering more information about the voices without addressing the patient's immediate emotional distress.
Choice D is incorrect because it shifts the focus away from the patient's current experience and onto distractions, which may not be helpful in addressing the patient's distressing symptoms.
Which of the following is the most common childhood mental disorder?
- A. ADHD
- B. Aspergers syndrome
- C. Conduct disorder
- D. Enuresis
Correct Answer: A
Rationale: ADHD (attention deficit/hyperactivity disorder) is the most common mental disorder in the 8 to 15 year old age group.
Which statement by a patient with borderline personality disorder best indicates the treatment plan is helping?
- A. I think you are the best nurse on the unit.'
- B. I hate my doctor. He never gives me what I ask for.'
- C. I feel empty and want to cut myself, so I called you.'
- D. I'm never going to get high on drugs again.'
Correct Answer: C
Rationale: The correct answer is C. This statement indicates progress because the patient is demonstrating insight into their emotions, seeking help, and utilizing a coping strategy by reaching out for support instead of engaging in self-harm. Choice A does not provide information about progress in treatment. Choice B reflects a negative attitude towards the doctor. Choice D does not offer any insight into the patient's emotional state or progress in managing their behaviors.
A 45-year-old man develops weakness and wasting of the right hand. Which one of the following is least likely to be the cause?
- A. Old injury to the elbow joint.
- B. Bronchogenic carcinoma of the right upper lobe.
- C. Multiple sclerosis.
- D. Syringomyelia.
Correct Answer: C
Rationale: Multiple sclerosis (C) typically causes sensory and motor symptoms but rarely isolated hand wasting, which is more characteristic of peripheral nerve or motor neuron issues. Old injury (A), lung cancer (B, via brachial plexus), syringomyelia (D), and motor neurone disease (E) are more directly linked to such symptoms.
An example of a Developmental Disorder is:
- A. ADHD
- B. Dyslexia
- C. Mental Retardation
- D. Autistic spectrum disorders
Correct Answer: D
Rationale: Autistic Spectrum Disorder (ASD): An umbrella term that refers to all disorders that display autistic style symptoms across a wide range of severity and disability.