Nokea
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.
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A patient with anorexia nervosa begins to refuse food. The nurse should first:
- A. Speak with the patient's family about the refusal.
- B. Focus on the patient's emotional distress and discuss it.
- C. Redirect the patient to a different activity to distract them.
- D. Encourage the patient to eat a small, manageable portion of food.
Correct Answer: D
Rationale: The correct answer is D because encouraging the patient to eat a small, manageable portion of food is the most immediate and vital intervention in addressing the patient's refusal to eat. This step is crucial in preventing further complications associated with anorexia nervosa, such as malnutrition and dehydration. By starting with a small portion, the patient can gradually reintroduce food and begin the process of recovery.
A: Speaking with the family may be important but not the first step in addressing the patient's refusal to eat.
B: Focusing on emotional distress is important but addressing the physical need for food should take priority.
C: Redirecting the patient to a different activity may temporarily distract them but does not address the underlying issue of malnutrition.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. Appropriately express angry feelings.
- B. Verbalize two positive things about self.
- C. Verbalize the importance of eating a balanced diet.
- D. Identify two alternative methods of coping with loneliness and isolation.
Correct Answer: D
Rationale: The correct answer is D: Identify two alternative methods of coping with loneliness and isolation.
Rationale:
1. The nursing diagnosis is Ineffective coping related to feelings of loneliness and isolation, indicating the patient struggles with coping mechanisms.
2. The desired outcome is for the patient to identify alternative coping methods, which directly addresses the ineffective coping issue.
3. By identifying two alternative methods, the patient demonstrates an understanding of healthier coping strategies.
4. This outcome focuses on addressing the root cause of the behavior (loneliness and isolation) rather than just surface-level expressions or behaviors.
Summary:
A: Appropriately expressing angry feelings does not directly address coping mechanisms related to loneliness and isolation.
B: Verbalizing positive things about oneself is beneficial but does not address the core issue of ineffective coping.
C: Verbalizing the importance of a balanced diet is important but does not directly address coping with loneliness and isolation.
The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on:
- A. Monitoring for the return of the capacity for full range of motion.
- B. Assessing the degree of accumulating memory impairment.
- C. Making positive comments while the patient is more receptive.
- D. Assessing the level of consciousness and normal body functions.
Correct Answer: D
Rationale: The correct answer is D: Assessing the level of consciousness and normal body functions. After electroconvulsive therapy (ECT), it is crucial to monitor the patient's level of consciousness and ensure all body functions are normal to detect any potential complications immediately. This includes assessing vital signs, neurological status, respiratory function, and cardiovascular stability. Monitoring for the return of full range of motion (A) is not a priority immediately post-ECT. Assessing memory impairment (B) may be important but is not the immediate priority. Making positive comments (C) is helpful for emotional support but does not address the critical need to assess physical status.
When a patient with anorexia nervosa expresses a fear of weight gain, the nurse should respond by:
- A. Minimizing the patient's concerns to avoid anxiety.
- B. Encouraging weight loss to meet the patient's goals.
- C. Explaining that weight gain is part of the treatment plan.
- D. Agreeing with the patient's view on body image to reduce conflict.
Correct Answer: C
Rationale: The correct response is C: Explaining that weight gain is part of the treatment plan. This answer is correct because in treating anorexia nervosa, it is essential for patients to understand that weight gain is necessary for recovery and overall health improvement. By explaining this, the nurse can help the patient develop a more positive attitude towards weight gain and recognize it as a crucial aspect of the treatment process.
Choices A, B, and D are incorrect:
A: Minimizing the patient's concerns may invalidate their feelings and hinder therapeutic communication.
B: Encouraging weight loss would be counterproductive and reinforce the patient's negative behaviors and beliefs.
D: Simply agreeing with the patient's view on body image without addressing the need for weight gain would not promote positive change or support the patient's recovery.
A 19-year-old client is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The client sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the client's condition as:
- A. Altered mood states
- B. Disturbed thinking
- C. Social isolation
- D. Poor impulse control
Correct Answer: B
Rationale: The correct answer is B: Disturbed thinking. In this scenario, the client's belief that her thoughts cause earthquakes and the world is burning are examples of delusions, which are a key symptom of schizophrenia. This demonstrates a disturbance in the client's thought process, indicating a primary deficit in thinking. Altered mood states (A) may be present as well but are not the primary deficit in this case. Social isolation (C) is a consequence of the client's symptoms rather than the primary deficit. Poor impulse control (D) is not the primary issue presented in the scenario.