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A 16-year-old client has anorexia nervosa. She has lost 50 pounds during the past 3 months and is about 20 pounds under the weight that is normal for her height. She has dry skin with poor turgor, hair breakage, and brittle nails. The nurse can anticipate that when giving information about her menstrual history, the client is likely to report:
- A. heavy menstrual flow.
- B. amenorrhea.
- C. premenstrual syndrome.
- D. dysmenorrhea.
Correct Answer: B
Rationale: The correct answer is B: amenorrhea. In anorexia nervosa, severe weight loss can disrupt the hormonal balance, leading to the cessation of menstruation, known as amenorrhea. This is due to the body conserving energy and prioritizing essential functions over reproductive processes. The client's significant weight loss and physical symptoms indicate a state of malnutrition, further supporting the likelihood of amenorrhea. The other choices (heavy menstrual flow, premenstrual syndrome, dysmenorrhea) are less likely because they are not typically associated with anorexia nervosa and severe weight loss. Amenorrhea is a common manifestation of anorexia nervosa and reflects the impact of malnutrition on reproductive health.
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To evaluate whether patient teaching for coping skills has been effective, the psychiatric-mental health nurse asks an adolescent patient to:
- A. consider the outcomes objectively
- B. keep a written journal
- C. perform a return demonstration
- D. set measurable goals
Correct Answer: C
Rationale: A return demonstration shows the patient can apply coping skills, providing tangible evidence of learning.
A 34-year-old client with residual schizophrenia frequently displays ambivalence. The community mental health nurse suggests that a realistic short-term outcome for this client problem is that client will:
- A. Decide his or her own daily schedule
- B. Refuse to attend activities
- C. Choose which clinic staff member to work with
- D. Choose between two outfits to wear each morning
Correct Answer: D
Rationale: The correct answer is D: Choose between two outfits to wear each morning. This outcome is realistic because it focuses on a concrete and manageable task that the client can achieve, promoting independence and decision-making skills. It also addresses the issue of ambivalence by providing the client with limited choices, which can help reduce anxiety and facilitate decision-making.
A: Decide his or her own daily schedule - This option may be too overwhelming for a client with residual schizophrenia and may not directly address the issue of ambivalence.
B: Refuse to attend activities - This option is negative and does not promote progress or independence for the client.
C: Choose which clinic staff member to work with - This option may not be directly related to the client's ambivalence or daily functioning, making it less relevant as a short-term goal.
The characteristic in individuals with personality disorders that makes it most necessary for staff to schedule frequent meetings is:
- A. flexibility and unconventional responses to stress.
- B. a desire to achieve emotional intimacy with staff.
- C. a tendency to evoke countertransference and conflict.
- D. an impaired ability to develop trusting relationships.
Correct Answer: C
Rationale: The correct answer is C because individuals with personality disorders often evoke countertransference and conflict in staff due to their challenging behaviors and interpersonal dynamics. This can lead to potential misunderstandings and ineffective treatment if not addressed through frequent meetings. Option A is incorrect as flexibility and unconventional responses to stress are not typically the primary concern necessitating frequent meetings. Option B is incorrect as a desire for emotional intimacy is not necessarily a reason for staff to schedule frequent meetings. Option D is incorrect as an impaired ability to develop trusting relationships might be a symptom of a personality disorder, but it is not the characteristic that most necessitates frequent meetings.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient is displaying symptoms such as restlessness, disorganized behavior, nonsensical verbal responses, disorientation, hot and dry skin, and dilated pupils, which are indicative of anticholinergic toxicity.
Step-by-step rationale:
1. Restlessness and disorganized behavior are common symptoms of anticholinergic toxicity.
2. Nonsensical verbal responses and disorientation are also typical signs of anticholinergic toxicity.
3. Hot and dry skin can be caused by decreased sweating due to anticholinergic effects.
4. Dilated pupils are a classic sign of anticholinergic toxicity.
5. Checking vital signs and preparing to use a cooling blanket is the appropriate immediate action to manage anticholinergic toxicity.
Summary of other choices:
- B: Relapse of psychosis does not explain the physical symptoms like dilated pupils and hot/dry skin.
- C: Neuroleptic malignant syndrome presents with
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
- A. Are you thinking of harming yourself?
- B. It will take time, but you will feel the same.
- C. Your friends will understand when you explain it was not your fault.
- D. You will be able to find meaning in this experience as time goes on.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.