Nokea
A nurse caring for a patient with bulimia nervosa should teach the patient about:
- A. Self-monitoring of daily food and fluid intake.
- B. Establishing the desired daily weight gain.
- C. Symptoms of hypokalemia.
- D. Self-esteem maintenance.
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
1. Patients with bulimia nervosa often engage in purging behaviors, leading to electrolyte imbalances.
2. Hypokalemia is a common complication due to vomiting, which can have serious consequences.
3. Educating the patient about hypokalemia symptoms is crucial for early detection and intervention to prevent complications.
Summary of Incorrect Choices:
A. Self-monitoring of food intake is important but not the priority as addressing electrolyte imbalances.
B. Weight gain is not a recommended goal for patients with bulimia nervosa.
D. While self-esteem maintenance is important, addressing acute physical health risks takes precedence.
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An adolescent claims to have been physically abused by a parent. The adolescent's other parent angrily tells the nurse, 'It's ridiculous for our child to accuse my spouse, who's a prominent doctor and is respected by the community.' Which of these nursing communications would be most effective for the parent?
- A. You believe that abuse does not exist in well-respected, professional families?'
- B. Your spouse seems to have a very stressful, demanding practice. That can be a risk factor for losing your temper when angry.'
- C. I know that it is difficult to believe what your child is saying about your spouse, but abuse has occurred.'
- D. I know your spouse from working in the emergency room. Your spouse is always kind to patients, but that can be misleading.'
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. This response challenges the parent's belief that abuse does not exist in respected families, highlighting the misconception that abuse can happen in any family.
2. It addresses the parent's disbelief directly, encouraging them to reconsider their assumptions and beliefs about abuse.
3. It promotes critical thinking and reflection on the parent's part, fostering a more open-minded and empathetic approach towards the adolescent's disclosure.
Summary of Other Choices:
B: This choice focuses on the stress of the accused parent, deflecting from the issue of abuse and potentially excusing their behavior.
C: This choice acknowledges the difficulty of the situation but does not effectively challenge the parent's disbelief or misconceptions about abuse.
D: This choice uses a positive characteristic of the accused parent to deflect from the allegations of abuse, which does not address the parent's denial or the seriousness of the situation.
When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a 'zombie.' What other common side effects should the nurse determine if the patient experienced?
- A. Sweating, nausea, and weight gain
- B. Sedation, tremor, and muscle stiffness
- C. Headache, watery eyes, and runny nose
- D. Mild fever, sore throat, and skin rash
Correct Answer: B
Rationale: The correct answer is B: Sedation, tremor, and muscle stiffness. This is because chlorpromazine, being a first-generation antipsychotic, commonly causes sedation, tremors, and muscle stiffness as side effects. Sedation is a common effect due to the drug's ability to block dopamine receptors in the brain. Tremors and muscle stiffness are also common due to the drug's action on the central nervous system. Choices A, C, and D are incorrect as they do not align with the expected side effects of chlorpromazine. Sweating, nausea, weight gain, headache, watery eyes, runny nose, mild fever, sore throat, and skin rash are not typically associated with this medication.
After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires persistent direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of:
- A. side effects of antipsychotic medications.
- B. dependency caused by institutionalization.
- C. cognitive deterioration from schizophrenia.
- D. stress associated with acclimation to the community.
Correct Answer: B
Rationale: Institutions impede independent functioning, fostering dependency (B) over time as daily activities are directed by staff. Antipsychotic side effects (A) and cognitive issues (C) may contribute, but the scenario suggests institutional adaptation. Stress (D) is less likely the primary cause.
Which point should be included in teaching patients and families about relapse?
- A. Patients who relapse are those who have failed to take their medications.
- B. Caffeine and nicotine can reduce the effectiveness of antipsychotic drugs.
- C. With support, education, and adherence to treatment, patients will not relapse.
- D. Posthospitalization education about medication side effects is usually ineffective.
Correct Answer: B
Rationale: Step-by-step rationale for why answer B is correct:
1. Caffeine and nicotine are known to reduce the effectiveness of antipsychotic drugs.
2. Teaching patients and families about this can help them understand the importance of avoiding these substances.
3. By avoiding caffeine and nicotine, patients can improve the effectiveness of their treatment and reduce the risk of relapse.
4. This information empowers patients and families to make informed decisions to support treatment outcomes.
Summary of why other choices are incorrect:
A: Incorrect because relapse can occur due to various factors, not just medication non-adherence.
C: Incorrect because relapse is a complex issue that may not be entirely prevented even with support, education, and adherence.
D: Incorrect because education about medication side effects is still valuable, even if it may not entirely prevent relapse.
The nurse is aware, when developing a care plan, that the three major goals of care for the client in whom Alzheimer's disease has been diagnosed include providing for the client's safety and well-being, therapeutically managing the client's behaviors, and:
- A. Supporting the client during curative care
- B. Providing support for family, relatives, and caregivers
- C. Arranging for nursing home placement
- D. Tracking the progress of medical, legal, and financial records
Correct Answer: B
Rationale: The correct answer is B: Providing support for family, relatives, and caregivers. This is because Alzheimer's disease not only affects the individual but also has a significant impact on their family and caregivers. Providing support to them is crucial for maintaining the overall well-being of the client. Choice A is incorrect as Alzheimer's disease does not have a curative treatment. Choice C is incorrect as nursing home placement is not always necessary and should be considered as a last resort. Choice D is incorrect as tracking medical, legal, and financial records is important but not a major goal in the care plan for Alzheimer's clients. Supporting the family and caregivers helps in creating a supportive environment for the client and ensures holistic care.