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A client with anorexia nervosa has refused meal trays and supplemental feedings for 3 days following admission to the general hospital. The nurse can anticipate that intervention will include:
- A. IV infusions beginning immediately and continuing for 48 hours after client begins eating.
- B. Tube feedings until the client eats 90% of all meals for 1 day.
- C. Placing the client on suicide precautions and one-to-one observation.
- D. Limiting peer group visitors for 2 weeks.
Correct Answer: B
Rationale: The correct answer is B. Tube feedings until the client eats 90% of all meals for 1 day. This intervention is appropriate for a client with anorexia nervosa who is refusing to eat. Tube feedings ensure adequate nutrition while also encouraging the client to resume eating orally. It is a gradual approach that aims to transition the client back to regular eating habits.
Explanation for why other choices are incorrect:
A: IV infusions are not the first-line intervention for a client with anorexia nervosa refusing to eat. This choice does not address the underlying issue of the client's refusal to eat.
C: Placing the client on suicide precautions and one-to-one observation is not indicated solely based on refusal to eat. This choice does not address the nutritional needs of the client.
D: Limiting peer group visitors for 2 weeks does not address the client's refusal to eat and is not a relevant intervention in this situation.
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A patient with schizophrenia tells the nurse 'I don't know, it's just all the same. You never know. It comes, it goes, it blows away. Get it?' The best response for the nurse to make would be:
- A. Nothing you are saying is clear; you are not making sense.'
- B. Yes, life can be like that sometimes, very confusing.'
- C. Try to organize your thoughts and then tell me again.'
- D. I am having difficulty understanding what you are saying.'
Correct Answer: D
Rationale: The correct answer is D because it reflects active listening and acknowledges the patient's communication difficulties without being dismissive. By stating difficulty in understanding, the nurse shows empathy and openness to further clarification. Choice A is incorrect as it may be perceived as judgmental. Choice B is incorrect as it does not address the patient's communication challenges. Choice C is incorrect as it places the responsibility solely on the patient without offering support.
A patient with borderline personality disorder has been making steady progress but one day gets a phone call from her boyfriend, who breaks off their relationship. Although she has not self-injured in over 2 months, she makes repeated lacerations on her forearm. Which statement about this and most maladaptive behaviors seen in personality disorders is most accurate?
- A. People with personality disorders rarely achieve lasting improvement.
- B. However dysfunctional, most behavior is the person's best effort to cope.
- C. People with personality disorders are at the mercy of others' actions.
- D. What appears to be improvement can be manipulation instead.
Correct Answer: B
Rationale: The correct answer is B: However dysfunctional, most behavior is the person's best effort to cope.
Rationale:
1. People with borderline personality disorder often struggle with intense emotions and unstable relationships.
2. Self-injury is a maladaptive coping mechanism used to manage overwhelming emotions or distress.
3. In this scenario, the patient resorts to self-injury as a coping strategy after the breakup triggers intense emotional pain.
4. Despite being maladaptive, the behavior serves as a coping mechanism to regulate emotions.
5. Understanding that maladaptive behaviors are often the individual's best attempt to cope helps in providing non-judgmental support and promoting healthier coping strategies.
Summary:
A: Incorrect. People with personality disorders can make progress with appropriate treatment and support.
C: Incorrect. While external factors may trigger behaviors, individuals with personality disorders have agency in their actions.
D: Incorrect. Improvement in behavior should not always be viewed as manipulation; it can indicate genuine progress in coping skills.
A nurse assesses that which of the following individuals is most likely to engage in eating behaviors characteristic of bulimia?
- A. A person who weighs 225 pounds and is 5 feet 4 inches tall.
- B. A person who is 5 pounds overweight and cannot stick to a diet.
- C. A person who lost up to 40 pounds but gained it back within 1 year.
- D. None of the above.
Correct Answer: A
Rationale: Step 1: Individuals with bulimia often engage in episodes of binge eating followed by purging behaviors.
Step 2: Choice A, a person who is significantly overweight, is more likely to engage in binge eating behavior.
Step 3: Being overweight can be a risk factor for bulimia due to body image concerns.
Step 4: Choices B and C do not provide as strong indicators for bulimia as choice A.
Summary: Choice A is correct as being significantly overweight is a common characteristic of individuals with bulimia. Choices B and C lack the same level of risk factors for engaging in eating behaviors characteristic of bulimia.
A nurse is assessing a patient with anorexia nervosa. Which of the following findings would be a priority for intervention?
- A. Weight loss of 2 pounds over the past week.
- B. Denial of the need for nutrition rehabilitation.
- C. Body image disturbance and self-imposed starvation.
- D. Refusal to participate in social activities.
Correct Answer: C
Rationale: The correct answer is C: Body image disturbance and self-imposed starvation. This is a priority because it directly addresses the core issues of anorexia nervosa and poses immediate risks to the patient's health. Body image disturbance contributes to the patient's self-imposed starvation, which can lead to severe malnutrition and other serious complications. Addressing this issue is crucial for the patient's well-being.
A: Weight loss of 2 pounds over the past week is concerning but may not be an immediate priority compared to addressing the underlying psychological issues.
B: Denial of the need for nutrition rehabilitation is important to address but may not pose an immediate threat to the patient's health compared to self-imposed starvation.
D: Refusal to participate in social activities may be a consequence of anorexia nervosa but does not directly address the urgent need to address body image disturbance and self-imposed starvation.
A widow, aged 72 years, lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the son visited today, he found his mother confused and disoriented, with an unsteady gait. The nurse assessed the patient as having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms that the patient's symptoms developed:
- A. Over the past few days.
- B. Over the past few weeks.
- C. Over the past few months.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Over the past few days. The sudden onset of confusion, disorientation, and cognitive deficits in the elderly patient suggests an acute change in her condition. This acute change is more indicative of a recent event or medication-related issue rather than a gradual decline over weeks or months. The sudden onset could be due to factors such as medication interactions, overdose, or underlying medical conditions. It is crucial to investigate recent changes in medications, lab results, or any other potential triggers that might have led to this acute cognitive decline. Choices B, C, and D are incorrect because they imply a gradual decline over weeks, months, or no specific timeframe, which does not align with the sudden onset observed in the patient.