Nokea
A client in the cardiac clinic tells the nurse that he is concerned about his mother, age 75, who lives alone and seems more forgetful. Which statement would be most indicative that the mother may have Alzheimer's disease?
- A. Mom continues to participate in senior center activities each week.'
- B. Mom insists on cooking and cleaning for herself.'
- C. Mom forgot to pay her utility bills last month.'
- D. Mom refuses to stop driving even though her reaction time is very slow.'
Correct Answer: C
Rationale: The correct answer is C because forgetting to pay bills is a common early symptom of Alzheimer's disease due to cognitive decline affecting memory and executive functions. This behavior indicates difficulty with organizing and managing tasks, a hallmark of Alzheimer's. Choices A and B suggest independence and engagement, which are not necessarily indicative of Alzheimer's. Choice D hints at potential safety concerns but does not directly point to cognitive decline related to Alzheimer's.
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An elderly patient with dementia paces the hallway and often engages in wandering. The nurse documents that the patient is exhibiting which type of behavior that is characteristic of dementia?
- A. Passive behavior
- B. Functionally impaired behavior
- C. Involuntary psychomotor behavior
- D. Nonaggressive psychomotor behavior
Correct Answer: D
Rationale: The correct answer is D: Nonaggressive psychomotor behavior. In dementia, wandering and pacing are common behaviors due to cognitive impairment. Nonaggressive behavior refers to actions that do not involve harm or aggression towards others. The patient's behavior is voluntary and purposeless, indicating psychomotor involvement. Choices A, B, and C do not accurately describe the behavior exhibited by the patient with dementia. Passive behavior implies lack of engagement, functionally impaired behavior suggests difficulty performing activities of daily living, and involuntary psychomotor behavior implies actions beyond the patient's control, which are not the case in this scenario.
What is an important aspect of managing refeeding syndrome in patients with anorexia nervosa?
- A. Refeeding the patient with high-calorie foods immediately.
- B. Monitoring electrolytes closely during the refeeding process.
- C. Allowing the patient to eat whatever they want without restrictions.
- D. Restricting fluid intake to avoid water retention.
Correct Answer: B
Rationale: The correct answer is B because monitoring electrolytes closely during refeeding is crucial to prevent life-threatening complications such as electrolyte imbalances. Refeeding syndrome can lead to shifts in electrolytes, particularly phosphorus, potassium, and magnesium, which may result in cardiac arrhythmias, respiratory failure, or even death. Close monitoring allows for timely interventions to maintain electrolyte balance.
Choice A is incorrect because refeeding a patient with high-calorie foods immediately can actually exacerbate refeeding syndrome by overwhelming the body's metabolic and electrolyte regulation processes. Choice C is incorrect because allowing the patient to eat whatever they want without restrictions can lead to rapid and uncontrolled weight gain, which may worsen medical complications. Choice D is incorrect because restricting fluid intake can also contribute to electrolyte imbalances and dehydration during refeeding.
The chief distinguishing feature of psychotic disorders is
- A. confusion of fantasy and reality
- B. antisocial conduct
- C. overwhelming anxiety
- D. obsessive behavior
Correct Answer: A
Rationale: Psychotic disorders are characterized by a loss of reality testing, such as hallucinations and delusions, distinguishing them from other conditions.
A nurse is caring for a patient diagnosed with anorexia nervosa. What is the most important intervention during the refeeding phase?
- A. Monitor weight gain and provide a structured meal plan.
- B. Encourage the patient to eat independently without supervision.
- C. Focus on psychological therapy to address emotional issues.
- D. Offer the patient high-calorie, high-fat foods to increase intake.
Correct Answer: A
Rationale: The correct answer is A because during the refeeding phase of anorexia nervosa, monitoring weight gain and providing a structured meal plan are crucial to prevent refeeding syndrome and ensure a safe and gradual increase in caloric intake. This approach helps prevent complications such as electrolyte imbalances and organ dysfunction. Encouraging the patient to eat independently without supervision (B) can be harmful as they may not consume adequate or balanced nutrition. Psychological therapy (C) is important but not the most crucial during the refeeding phase. Offering high-calorie, high-fat foods (D) can lead to rapid weight gain and further complications.
A nurse is caring for a patient with bulimia nervosa who has not eaten for 24 hours. The nurse should first:
- A. Encourage the patient to eat a full meal immediately.
- B. Assess the patient's vital signs and hydration status.
- C. Provide the patient with a menu to select food for the next meal.
- D. Contact the physician for a medication prescription.
Correct Answer: B
Rationale: The correct answer is B because assessing vital signs and hydration status is crucial in identifying potential complications from prolonged fasting in a patient with bulimia nervosa. This step helps determine the patient's immediate needs for intervention and guides further care planning. Encouraging the patient to eat a full meal immediately (Choice A) may lead to refeeding syndrome due to electrolyte imbalances. Providing a menu for the next meal (Choice C) is not the priority when the patient has not eaten for 24 hours. Contacting the physician for a medication prescription (Choice D) is not necessary at this point without first assessing the patient's current physical status.