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A healthcare professional is assessing a patient with anorexia nervosa. Which finding is most concerning?
- A. Mild bradycardia
- B. Electrolyte imbalances
- C. Slight hypotension
- D. Lanugo
Correct Answer: B
Rationale: The correct answer is B: Electrolyte imbalances. In anorexia nervosa, electrolyte imbalances can lead to serious complications like cardiac arrhythmias and even sudden death. This is the most concerning finding as it directly impacts the patient's health and can be life-threatening. Bradycardia (choice A) is common in anorexia but usually reversible with treatment. Slight hypotension (choice C) may occur due to dehydration but can be managed. Lanugo (choice D) is a reversible side effect of malnutrition and not as concerning as electrolyte imbalances.
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A patient is experiencing a manic episode. Which intervention is most effective?
- A. Encouraging the patient to participate in group activities
- B. Providing a low-stimulation environment
- C. Allowing the patient to move freely around the unit
- D. Engaging the patient in competitive games
Correct Answer: B
Rationale: The correct answer is B: Providing a low-stimulation environment. This is effective because it helps reduce excessive sensory input which can trigger or exacerbate manic symptoms. Manic patients are often sensitive to stimuli, so a calm and quiet environment can help in de-escalating their agitation and hyperactivity.
A: Encouraging group activities can be overwhelming for a manic patient due to the increased stimulation and potential for overstimulation.
C: Allowing free movement may lead to risky behaviors or agitation, as the patient may not be able to self-regulate effectively.
D: Engaging in competitive games can escalate the manic symptoms and potentially lead to aggressive or impulsive behaviors.
In summary, providing a low-stimulation environment is the most effective intervention as it helps manage manic symptoms by reducing triggers and promoting a sense of calm.
A patient with major depressive disorder is started on fluoxetine. What is a common side effect the nurse should monitor for?
- A. Weight gain
- B. Increased appetite
- C. Nausea
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Nausea. Fluoxetine, an SSRI antidepressant, commonly causes gastrointestinal side effects such as nausea. This is due to its effect on serotonin levels in the gut. Weight gain (A) and increased appetite (B) are less common side effects of fluoxetine. Dry mouth (D) is more commonly associated with tricyclic antidepressants, not SSRIs. Monitoring for nausea is crucial to ensure patient compliance and well-being.
A patient with generalized anxiety disorder is being taught about buspirone. Which statement indicates the patient needs further teaching?
- A. I should take this medication consistently rather than on an as-needed basis.
- B. It may take a few weeks to feel the full effect of this medication.
- C. This medication has a lower risk of dependency compared to benzodiazepines.
- D. I should avoid drinking alcohol while taking this medication.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Buspirone is not meant for immediate relief, so taking it consistently is crucial for its effectiveness.
2. Buspirone takes time to build up in the body and show its full effect, usually a few weeks.
3. Buspirone is known for having a lower risk of dependency compared to benzodiazepines.
4. Taking buspirone consistently is essential, unlike benzodiazepines which are often taken on an as-needed basis.
Therefore, choice A is incorrect as it goes against the appropriate usage of buspirone for treating generalized anxiety disorder.
When developing a care plan for a patient with borderline personality disorder, which intervention should be included to address self-harm behaviors?
- A. Encouraging the patient to keep a journal of their thoughts and feelings.
- B. Setting clear and consistent boundaries with the patient.
- C. Providing the patient with coping skills to manage their emotions.
- D. Developing a safety plan with the patient.
Correct Answer: D
Rationale: The correct answer is D, developing a safety plan with the patient. This intervention is crucial for addressing self-harm behaviors in patients with borderline personality disorder. A safety plan helps the patient identify triggers, warning signs, coping strategies, and support networks to prevent self-harm. It also outlines specific steps to take in a crisis situation. This intervention is more direct and practical compared to the other options.
A: Keeping a journal may be helpful for self-reflection but may not provide immediate strategies to prevent self-harm.
B: Setting boundaries is important but may not directly address self-harm behaviors.
C: Providing coping skills is beneficial, but a safety plan is more specific and tailored to managing self-harm risks.
In summary, developing a safety plan is the most effective intervention for addressing self-harm behaviors in patients with borderline personality disorder.
In cognitive processing therapy for PTSD, what is the primary goal for the patient?
- A. To help the patient process the trauma and reduce avoidance behaviors.
- B. To help the patient confront and process the trauma in a safe environment.
- C. To help the patient understand the impact of the trauma on their current thoughts and behaviors.
- D. To help the patient avoid triggers that remind them of the trauma.
Correct Answer: C
Rationale: The correct answer is C because the primary goal of cognitive processing therapy in PTSD is to help the patient understand the impact of trauma on their current thoughts and behaviors. This involves identifying and challenging maladaptive beliefs and cognitive distortions related to the trauma. By gaining insight into how the trauma has influenced their thoughts and behaviors, the patient can work towards changing these patterns and improving their psychological well-being.
Choice A is incorrect because while processing the trauma and reducing avoidance behaviors are important aspects of therapy, they are not the primary goal in cognitive processing therapy. Choice B is incorrect as it focuses solely on confronting and processing the trauma, missing the crucial component of understanding its impact on thoughts and behaviors. Choice D is incorrect because avoidance of triggers is not the primary goal; rather, it is about addressing and modifying the cognitive responses to those triggers.