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A Hispanic woman comes to the mental health center at the urging of her adult children. The patient has lost 5 pounds since her husband's death 6 months ago and says, "My husband comes to visit me in the night but I cannot understand what he says." How should the nurse analyze this situation? The patient is:
- A. Experiencing auditory and visual hallucinations.
- B. At high risk for imbalanced nutrition.
- C. Grieving the husband's death.
- D. Denying the husband's death.
Correct Answer: C
Rationale: The correct answer is C: Grieving the husband's death. The patient's statement about her deceased husband visiting her in the night and her weight loss following his death indicate a strong possibility of experiencing grief. This is a common manifestation of bereavement, where individuals may have difficulty accepting the reality of the loss and experience hallucinations or illusions involving the deceased. The patient's symptoms are more aligned with the normal process of grieving rather than psychosis. Choices A and B are incorrect because the patient's experiences are likely related to grief rather than auditory and visual hallucinations or imbalanced nutrition. Choice D is incorrect as the patient's statements suggest she is aware of her husband's death but is struggling to cope with it emotionally.
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A man who regularly experiences premature ejaculation tells the nurse, 'I feel like such a failure. It's so awful for both me and my partner.' Select the nurse's most therapeutic response.
- A. I sense you are feeling frustrated and upset.
- B. Tell me more about feeling like a failure.
- C. You are too hard on yourself.
- D. What do you mean by awful?
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the man's emotions of frustration and upset, showing empathy and understanding. This response validates his feelings and opens the door for further discussion. Choice B shifts the focus away from the man's current emotions. Choice C minimizes his feelings and may come across as dismissive. Choice D is too vague and doesn't address the man's emotional state directly. Overall, choice A is the most therapeutic as it validates the man's feelings and encourages him to express more.
What is the most important aspect of nursing care for patients with anorexia nervosa during refeeding?
- A. Refeed the patient with high-calorie foods quickly to gain weight.
- B. Start with small, manageable portions and gradually increase caloric intake.
- C. Restrict food choices to healthy foods only.
- D. Encourage the patient to take food supplements in addition to meals.
Correct Answer: B
Rationale: The correct answer is B: Start with small, manageable portions and gradually increase caloric intake. This approach is essential because refeeding syndrome can occur in patients with anorexia nervosa, where rapid refeeding can lead to severe electrolyte imbalances and potentially life-threatening complications. Starting with small portions helps to prevent this syndrome by allowing the body to gradually adjust to increased caloric intake. Additionally, it helps in preventing overwhelming the patient with large amounts of food, which can trigger anxiety and resistance to eating.
Incorrect choices:
A: Refeed the patient with high-calorie foods quickly to gain weight - This can lead to refeeding syndrome and is not a safe approach.
C: Restrict food choices to healthy foods only - Restricting food choices can exacerbate disordered eating behaviors and does not address the need for gradual refeeding.
D: Encourage the patient to take food supplements in addition to meals - While supplements can be helpful, they should not be a primary focus over balanced
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. tardive dyskinesia"¦seek a change in the drug or its dosage
- C. waxy flexibility"¦continue treatment with antipsychotic drugs
- D. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
Correct Answer: A
Rationale: The correct answer is A: a dystonic reaction"¦administer PRN IM benztropine (Cogentin).
1. Dystonic reaction is characterized by involuntary muscle contractions, causing abnormal posture or movements.
2. The patient's symptoms of head rotation, jaw thrust, and severe anxiety align with dystonic reaction.
3. Benztropine is an anticholinergic medication used to treat dystonic reactions by blocking acetylcholine in the brain.
4. Administering benztropine promptly can alleviate the symptoms and prevent complications.
Other choices are incorrect:
B: Tardive dyskinesia develops with long-term antipsychotic use, presenting as repetitive, involuntary movements. Seeking a change in drug or dosage is not appropriate for acute dystonic reaction.
C: Waxy flexibility is a symptom of catatonia, not related to the patient's presentation of dystonic reaction.
D: Akathisia is restlessness and agitation often caused by
Which finding is most indicative of refeeding syndrome in a patient with anorexia nervosa?
- A. Increased energy and mental clarity after eating.
- B. Electrolyte imbalances, particularly hypophosphatemia.
- C. A sudden increase in appetite and food cravings.
- D. Rapid weight gain and hypertension.
Correct Answer: B
Rationale: The correct answer is B because refeeding syndrome is characterized by electrolyte imbalances, especially hypophosphatemia, due to rapid reintroduction of nutrition. This can lead to serious complications like cardiac arrhythmias and respiratory failure. Increased energy and mental clarity (A) are not specific to refeeding syndrome. A sudden increase in appetite and food cravings (C) may occur but are not indicative of refeeding syndrome. Rapid weight gain and hypertension (D) are not typically seen in refeeding syndrome.
The mother of a teen with an eating disorder tells the nurse, 'Our family is pretty well-adjusted. It's hard for me to imagine what we could have done to have this happen.' The nurse can promote more complete understanding of the etiology of eating disorders by mentioning that young women are also influenced by:
- A. The abundance of nutritious foods available.
- B. The fashion industry's idealization of thinness.
- C. Competition in the workplace.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: The fashion industry's idealization of thinness. This is correct because the portrayal of ultra-thin models in the fashion industry can contribute to societal pressure on young women to achieve an unrealistic body image, leading to body dissatisfaction and potentially eating disorders. The other choices are incorrect because option A does not address the societal influences on body image ideals, option C is not directly related to the etiology of eating disorders in young women, and option D is incorrect as the fashion industry can indeed play a significant role in shaping perceptions of beauty and body image.