Nokea
A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, 'I get lonely and drink a little to help me forget.' Select the nurses most therapeutic intervention.
- A. Assess whether this patient is drinking and driving
- B. Advise the person not to drink alone because the risks for injury increase
- C. Teach the person about risks for alcoholism and suggest other coping strategies
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults
Correct Answer: D
Rationale: This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance.
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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." 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 symptoms indicate severe malnutrition from self-starvation, leading to the yellow skin, cold extremities, low heart rate, and underweight status. The patient's statement reflects their distorted perception of body image and the extreme measures taken to achieve thinness. Choice A (Anxiety related to fear of weight gain) is not the best initial diagnosis as it focuses on anxiety rather than the critical issue of malnutrition. Choice B (Disturbed body image related to weight loss) is not the best initial diagnosis as it does not address the immediate risk of severe malnutrition. Choice C (Ineffective coping related to lack of conflict resolution skills) is not the best initial diagnosis as it does not prioritize the life-threatening malnutrition present in this case.
Which data gathered from the assessment of a family with a schizophrenic member would be of greatest importance in discharge planning for the patient?
- A. The patient is the middle sibling.
- B. The patient's mother is a talented artist.
- C. The patient's paternal grandfather was considered 'eccentric.'
- D. The patient becomes anxious when family members are critical of one another.
Correct Answer: D
Rationale: The correct answer is D because understanding how the patient reacts to family dynamics is crucial for discharge planning. Anxiety triggered by family conflict can impact the patient's well-being post-discharge. Choices A, B, and C are less relevant as they do not directly address the patient's immediate needs or potential stressors. Middle sibling status, maternal artistic talent, and paternal grandfather's eccentricity are interesting but not as directly impactful on the patient's discharge planning compared to the patient's response to family conflicts.
The caregiver for a client with moderate to severe dementia tells the nurse, 'I'm exhausted. He wanders at night instead of sleeping, so I get no rest. I'm afraid to leave him during the day, so I have to take him to the grocery store and to the laundromat. When I'm busy there, he often wanders off. Still, I have to do it all.' The nurse recognizes the need to provide teaching for this caregiver. An appropriate outcome is that the caregiver will:
- A. Feel justified in putting the client in a nursing home
- B. Verbalize realistic self-expectations
- C. Cease abusive interactions with the client
- D. Feel comfortable leaving the client alone one morning a week
Correct Answer: B
Rationale: The correct answer is B: Verbalize realistic self-expectations. This is the most appropriate outcome to address the caregiver's situation. By verbalizing realistic self-expectations, the caregiver can understand the importance of self-care and setting boundaries. This outcome promotes the caregiver's well-being while still providing care for the client.
Choice A is incorrect because putting the client in a nursing home may not be the best solution without exploring other options first. Choice C is incorrect as there is no mention of abusive interactions in the scenario. Choice D is incorrect because feeling comfortable leaving the client alone without addressing the caregiver's exhaustion and concerns may not be the most appropriate approach.
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?
- A. Eating disorder not otherwise specified
- B. Anorexia nervosa
- C. Bulimia nervosa
- D. Binge eating
Correct Answer: B
Rationale: The correct diagnosis is B: Anorexia nervosa. This patient exhibits key symptoms such as restrictive eating leading to significant weight loss, wearing layers of clothing to hide body shape, and amenorrhea. These symptoms align with the diagnostic criteria for anorexia nervosa. The other choices are incorrect because they do not fully capture the combination of symptoms present in this case. Choice A (Eating disorder not otherwise specified) is too broad and does not specify the severity of the symptoms. Choice C (Bulimia nervosa) typically involves binge eating followed by compensatory behaviors, which is not indicated in this case. Choice D (Binge eating) focuses solely on overeating without the restrictive eating and weight loss seen in anorexia nervosa.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.