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A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa?
- A. I'm fat and ugly.
- B. What I think about myself is my business.
- C. I'm grossly underweight, but I cover it well.
- D. I'm a few pounds overweight, but I can live with it.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. The patient's history of significant weight loss and refusal to eat align with symptoms of anorexia nervosa.
2. Choice A reflects negative body image common in anorexia nervosa, as patients often perceive themselves as overweight and unattractive.
3. Choices B, C, and D do not acknowledge the patient's actual physical condition or the psychological aspect of anorexia nervosa.
4. Choice B avoids the question and lacks insight into the patient's distorted body image.
5. Choice C acknowledges being underweight but does not address the negative self-perception associated with anorexia nervosa.
6. Choice D acknowledges being overweight, which contradicts the patient's actual weight loss history and is inconsistent with anorexia nervosa's symptoms.
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The plan of care for a patient who has demonstrated outbursts of physical violence against his family when frustrated, followed by periods of remorse after each outburst, would be considered successful when the patient:
- A. Expresses frustration verbally instead of physically.
- B. Agrees to seek group counseling at a future time.
- C. Explains the reason for his behavior toward the victim.
- D. Identifies three personal strengths and coping strategies.
Correct Answer: A
Rationale: The correct answer is A because expressing frustration verbally instead of physically shows progress in managing emotions constructively. This approach helps prevent harm and promotes effective communication. Choice B doesn't address immediate behavior change. Choice C focuses on explaining behavior rather than changing it. Choice D is more about self-awareness and coping strategies, which is important but doesn't directly address the violent behavior.
A patient with many positive symptoms of schizophrenia, whose behavior is disorganized and who is highly anxious, tells the nurse in the psychiatric emergency department, 'You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun.' The patient, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend:
- A. admission to an unlocked residential crisis unit.
- B. inpatient hospitalization on a locked unit.
- C. attending a day treatment program for 4 weeks.
- D. admission to a partial hospital program.
Correct Answer: B
Rationale: The correct answer is B: inpatient hospitalization on a locked unit. This option is the most appropriate given the patient's presentation. The patient is experiencing severe positive symptoms of schizophrenia, such as delusions and disorganized behavior, posing a risk to himself and others by expressing intent to obtain a gun. Additionally, the patient is neglecting basic needs, indicating a need for close monitoring and intervention. Inpatient hospitalization on a locked unit provides a structured and secure environment for intensive treatment, ensuring safety and stabilization.
Incorrect choices:
A: Admission to an unlocked residential crisis unit may not provide the level of monitoring and security needed for a patient with active psychotic symptoms and self-harm potential.
C: Attending a day treatment program for 4 weeks does not address the acute safety concerns and level of impairment displayed by the patient.
D: Admission to a partial hospital program may not offer the round-the-clock supervision and immediate intervention required for someone at risk of harming themselves or others.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient is displaying symptoms such as restlessness, disorganized behavior, nonsensical verbal responses, disorientation, hot and dry skin, and dilated pupils, which are indicative of anticholinergic toxicity.
Step-by-step rationale:
1. Restlessness and disorganized behavior are common symptoms of anticholinergic toxicity.
2. Nonsensical verbal responses and disorientation are also typical signs of anticholinergic toxicity.
3. Hot and dry skin can be caused by decreased sweating due to anticholinergic effects.
4. Dilated pupils are a classic sign of anticholinergic toxicity.
5. Checking vital signs and preparing to use a cooling blanket is the appropriate immediate action to manage anticholinergic toxicity.
Summary of other choices:
- B: Relapse of psychosis does not explain the physical symptoms like dilated pupils and hot/dry skin.
- C: Neuroleptic malignant syndrome presents with
A 16-year-old client has anorexia nervosa. She has lost 50 pounds during the past 3 months and is about 20 pounds under the weight that is normal for her height. She has dry skin with poor turgor, hair breakage, and brittle nails. The nurse can anticipate that when giving information about her menstrual history, the client is likely to report:
- A. heavy menstrual flow.
- B. amenorrhea.
- C. premenstrual syndrome.
- D. dysmenorrhea.
Correct Answer: B
Rationale: The correct answer is B: amenorrhea. In anorexia nervosa, severe weight loss can disrupt the hormonal balance, leading to the cessation of menstruation, known as amenorrhea. This is due to the body conserving energy and prioritizing essential functions over reproductive processes. The client's significant weight loss and physical symptoms indicate a state of malnutrition, further supporting the likelihood of amenorrhea. The other choices (heavy menstrual flow, premenstrual syndrome, dysmenorrhea) are less likely because they are not typically associated with anorexia nervosa and severe weight loss. Amenorrhea is a common manifestation of anorexia nervosa and reflects the impact of malnutrition on reproductive health.
Which factor most significantly impacts early mental development?
- A. Nutrition
- B. Sleep
- C. Genetics
- D. Play
Correct Answer: A
Rationale: Nutrition (A) is critical for early brain growth, providing essential nutrients for neural development. Sleep (B), genetics (C), and play (D) are important, but nutrition has the most direct and foundational impact in early years.