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A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
- A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
- B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
- C. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
- D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.
Correct Answer: A
Rationale: Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. Distraction does not focus on the client's need for control. Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.
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A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
- A. Water will deplete electrolytes resulting in metabolic acidosis.
- B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
- C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
- D. Saline will increase peristalsis in the bowel.
Correct Answer: A
Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.
A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?
- A. Thioridazine (Mellaril), lithium, and benztropine
- B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)
- C. Sodium, potassium, and magnesium
- D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)
Correct Answer: B
Rationale: Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. Atropine (a cholinergic blocker), sodium brevitol (a short-acting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to counteract bradycardia and to provide anesthesia and total muscle relaxation. These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. Carbamazepine (an anticonvulsant), haloperidol (an antipsychotic), and trihexyphenidyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in high-sugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?' The client's actions and response best demonstrate:
- A. Depression
- B. Anger
- C. Denial
- D. Bargaining
Correct Answer: C
Rationale: Depression may be an underlying feature, but it is not evident from limited data presented here. Anger is not exhibited in his response. Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. There is no evidence of bargaining in the client's actions or verbal response.
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
- A. Maintain O2 at <40%
- B. Maintain O2 at >40%
- C. Give moist O2 at >40%
- D. Maintain on 100% O2
Correct Answer: A
Rationale: Maintaining O2 at <40% minimizes the risk of retrolental fibroplasia, a complication of high oxygen levels in premature infants.
Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
- A. Distant breath sounds
- B. Increased heart sounds
- C. Decreased anteroposterior chest diameter
- D. Collapsed neck veins
Correct Answer: A
Rationale: Distant breath sounds are characteristic of emphysema due to increased anteroposterior chest diameter, overdistention, and air trapping.