A client with anorexia nervosa engages in manipulative behavior. She tells the nurse, 'I can't get weighed this morning, because I drank a glass of juice a few minutes before breakfast.' The best approach by the nurse would be:
- A. I'm pleased that you took in some calories.'
- B. We can get around this, if you'll eat a doughnut, too.'
- C. The rule is 'weigh before eating'; now we have to put it off until tomorrow.'
- D. This is weight day. Please step on the scale.'
Correct Answer: D
Rationale: Step 1: The correct answer is D because it sets clear boundaries and enforces consistency by reminding the client of the established protocol.
Step 2: By stating "This is weight day. Please step on the scale," the nurse maintains the structure and accountability in the treatment plan.
Step 3: This response avoids reinforcing manipulative behavior and emphasizes the importance of following the agreed-upon rules for accurate monitoring.
Step 4: Other choices like A may inadvertently validate the manipulation, B suggests giving in to the client's avoidance tactic, and C delays the weighing without addressing the manipulation directly.
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An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, 'It's awful to be old. Every day is a struggle. No one cares about old people.' Select the nurse's best response.
- A. Everyone here cares about old people. That's why we work here.
- B. It sounds like you're having a difficult time. Tell me about it.
- C. Let's not focus on the negative. Tell me something good.
- D. You are still able to get around, and your mind is alert.
Correct Answer: B
Rationale: The correct answer is B because it shows empathy and encourages the patient to express their feelings. By saying "Tell me about it," the nurse acknowledges the patient's struggle and opens up the opportunity for the patient to share more about their feelings and concerns. This can help build a therapeutic relationship and provide emotional support.
Choice A is incorrect because it dismisses the patient's feelings by making a general statement about everyone caring without addressing the patient's specific concerns.
Choice C is incorrect because it invalidates the patient's emotions by suggesting to focus on positivity without addressing the patient's current distress.
Choice D is incorrect because it minimizes the patient's struggle by only focusing on physical abilities and cognitive function without addressing the emotional aspect of the patient's statement.
When planning inpatient psychotherapeutic activities for a patient who has antisocial personality disorder, the psychiatric-mental health nurse:
- A. focuses on group, rather than individual, therapy
- B. provides a permissive atmosphere, so the patient feels a sense of control
- C. provides an organized, structured environment
- D. recognizes that the disorder is characterized by social withdrawal
Correct Answer: C
Rationale: A structured environment sets clear boundaries, countering manipulative tendencies common in antisocial personality disorder.
Which of the following is true regarding the management of oppositional behaviours in children?
- A. There are no circumstances in which oppositional behaviours are considered typical and expected of children
- B. Assessment of oppositional behaviours should consider individual, dyadic, systemic, and familial risk factors
- C. Psychosocial and pharmacological treatments are found to be equally effective in the management of oppositional behaviours
- D. Parenting involvement and training are not required in the management of oppositional behaviours
Correct Answer: B
Rationale: A comprehensive assessment considering individual, dyadic, systemic, and familial factors is true and essential for managing oppositional behaviors.
To cope with the devastating effects of schizophrenia and other serious mental illnesses, family members or significant others and clients will benefit most from:
- A. Regular psychoanalysis
- B. Intensive short-term therapy
- C. Ongoing treatment and support
- D. Continued medication adjustments
Correct Answer: C
Rationale: The correct answer is C: Ongoing treatment and support. This option is the most beneficial for coping with serious mental illnesses like schizophrenia because it involves long-term management and assistance. Ongoing treatment can include therapy, medication management, and support groups, which are crucial for helping individuals and their families manage symptoms and improve overall quality of life.
Explanation:
A: Regular psychoanalysis is not the most effective approach for managing the devastating effects of serious mental illnesses like schizophrenia. It may not provide the immediate support and intervention needed for crisis situations.
B: Intensive short-term therapy may offer temporary relief, but ongoing treatment and support are essential for long-term management and stability.
D: Continued medication adjustments are important, but they are just one aspect of a comprehensive treatment plan. Ongoing treatment and support encompass a broader range of interventions that are necessary for addressing the complex needs of individuals with serious mental illnesses.
A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, "I will not eat until I lose enough weight to look thin."Â Select the best initial nursing diagnosis.
- A. Anxiety related to fear of weight gain
- B. Disturbed body image related to weight loss
- C. Ineffective coping related to lack of conflict resolution skills
- D. Imbalanced nutrition: less than body requirements related to self-starvation
Correct Answer: D
Rationale: The correct initial nursing diagnosis is D: Imbalanced nutrition: less than body requirements related to self-starvation. The patient's presentation of yellow skin, cold extremities, bradycardia, low weight, and refusal to eat indicate severe malnutrition due to self-starvation. The key indicators are the physical signs of malnutrition and the patient's statement about not eating until they lose enough weight. Options A and B do not address the primary issue of malnutrition and self-starvation. Option C focuses on coping skills, which is not the priority in this case. Therefore, option D is the best initial nursing diagnosis to address the patient's life-threatening condition of malnutrition.