Nokea
A much-feared outcome of Alzheimer's disease is
- A. functional psychosis
- B. paranoia
- C. general paresis
- D. senile dementia
Correct Answer: D
Rationale: Senile dementia is a progressive cognitive decline feared in Alzheimer's, impairing memory and daily functioning.
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A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is 2.7 mg/dL. Which nursing diagnosis applies?
- A. Adult failure to thrive related to abuse of laxatives, as evidenced by electrolyte imbalances and weight loss
- B. Ineffective health maintenance related to self-induced vomiting, as evidenced by swollen parotid glands and hyperkalemia
- C. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake, as evidenced by weight loss and hyperkalemia
- D. Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia.
Rationale:
1. Anorexia nervosa involves severe restriction of food intake, leading to significant weight loss and malnutrition.
2. The patient's history of virtually stopping eating and losing 25% of body weight aligns with the nursing diagnosis of imbalanced nutrition.
3. Hypokalemia (low serum potassium level) is common in patients with anorexia nervosa due to inadequate intake or purging behaviors.
4. The other choices are incorrect because they do not match the patient's specific presentation of anorexia nervosa and hypokalemia.
A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacantly. You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
- A. Pain, self-care deficits, situational low self-esteem
- B. Anxiety, self-care deficits, disturbed thought processes
- C. Impaired home maintenance, disturbed thought process, impaired verbal communication
- D. Disturbed body image, anxiety, pain
Correct Answer: C
Rationale: The correct answer is C: Impaired home maintenance, disturbed thought process, impaired verbal communication.
Rationale:
1. Impaired home maintenance: The client is unable to take care of herself and her living environment due to the need for assistance in shopping, meal preparation, and finances.
2. Disturbed thought process: The client's vacant stare and inability to learn new tasks suggest cognitive impairment or confusion.
3. Impaired verbal communication: The client's lack of verbal interaction and reliance on her sister for assessment data indicate difficulties in expressing herself.
Summary:
A: Pain, self-care deficits, situational low self-esteem - Pain is not mentioned in the scenario, and the client's issues go beyond self-care deficits and low self-esteem.
B: Anxiety, self-care deficits, disturbed thought processes - While anxiety and disturbed thought processes may be present, impaired home maintenance and impaired verbal communication are more appropriate diagnoses based on the scenario.
D: Disturbed body image, anxiety, pain - Disturbed
Psychological dependence on mood- or behavior-altering drugs is known as
- A. drug psychosis
- B. a substance related disorder
- C. an orthopsychosis
- D. a psychotropic disorder
Correct Answer: B
Rationale: Substance-related disorders encompass psychological dependence on drugs altering mood or behavior.
Which of the following is a common complication of anorexia nervosa?
- A. Hypertension and hyperglycemia.
- B. Cardiovascular instability and electrolyte imbalances.
- C. Insulin resistance and excessive weight gain.
- D. Severe dehydration and frequent urination.
Correct Answer: B
Rationale: The correct answer is B: Cardiovascular instability and electrolyte imbalances. Anorexia nervosa can lead to severe malnutrition, causing cardiovascular issues like low heart rate and blood pressure. Electrolyte imbalances occur due to inadequate nutrient intake. Hypertension and hyperglycemia (choice A) are not common in anorexia. Insulin resistance and weight gain (choice C) are more associated with conditions like obesity. Severe dehydration and frequent urination (choice D) are not typical manifestations of anorexia.
Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness who is homeless?
- A. Insomnia
- B. Substance abuse
- C. Chronic low self-esteem
- D. Impaired environmental interpretation syndrome
Correct Answer: C
Rationale: Many individuals with serious mental illness do not live with their families and become homeless. Life on the street or in a shelter has a negative influence on the individuals self-esteem, making this nursing diagnosis one that should be considered. Substance abuse is not an approved NANDA-International diagnosis. Insomnia may be noted in some patients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless.