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A nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Select the nurse's best comment.
- A. It bothers me to see you exercising.
- B. You and I will have to sit down and discuss this problem.
- C. Let's discuss the relationship between exercise and weight loss and how that affects your body.
- D. According to our agreement, exercising is not permitted until you have gained a specific amount of weight.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the behavior in relation to the agreed-upon plan and sets clear boundaries. By stating that exercising is not permitted until the patient has gained a specific amount of weight, the nurse reinforces the importance of following the treatment plan to ensure the patient's health and well-being.
A: This response does not address the behavior in a constructive manner and may come across as judgmental.
B: While discussing the problem is important, it does not provide clear guidance on addressing the immediate issue of exercising before reaching the weight goal.
C: While discussing the relationship between exercise and weight loss can be helpful, it does not provide a clear directive on what action should be taken in this specific situation.
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In the OB follow-up clinic, your patient, who is 4 weeks post-delivery, tells you she is sleeping for long hours, wants to avoid taking care of the baby, and wishes she had never had the baby. What would be your first response?
- A. Its normal to feel overwhelmed at first.
- B. Tell me more about these feelings.
- C. Report her to Child Protective Services.
- D. Ill call your husband right away to get you back home to rest.
Correct Answer: B
Rationale: The open-ended question (B) will give you more information and be less judgmental to this patient. This behavior is not normal at 4 weeks post-delivery and more rest is probably not adequate treatment. You would like a lot more information before reporting this as neglect.
A 35-year-old woman who is being interviewed by the advanced practice nurse indicates that she has few friends, fears criticism from others, and withholds information about her thoughts and feelings because she anticipates a negative reaction. Based on these data, the nurse suspects that Sarah may later be diagnosed as having:
- A. Borderline personality disorder
- B. Histrionic personality disorder
- C. Avoidant personality disorder
- D. Schizoid personality disorder
Correct Answer: C
Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, avoidance of sharing thoughts/feelings, and limited social circle are indicative of social inhibition and feelings of inadequacy, which are key features of avoidant personality disorder.
A: Borderline personality disorder is characterized by unstable relationships, self-image, and emotions, as well as impulsivity and fear of abandonment.
B: Histrionic personality disorder involves attention-seeking behavior, emotions that are shallow and rapidly shifting, and the need to be the center of attention.
D: Schizoid personality disorder is marked by social detachment, limited emotional expression, and preference for solitary activities.
The client has been taking lithium and fluoxetine (Prozac) for almost a week. During today's assessment, the nurse notes a temperature of 39°C, muscle rigidity, and confusion. The client's signs and symptoms suggest:
- A. Dystonic reactions
- B. Bradykinesic side effects
- C. Extrapyramidal side effects
- D. Neuroleptic malignant syndrome
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). This is indicated by the client's elevated temperature, muscle rigidity, and confusion, which are classic symptoms of NMS. NMS is a serious, potentially life-threatening condition associated with the use of antipsychotic medications like lithium and fluoxetine. The onset of NMS is often rapid and can lead to severe complications if not treated promptly. Dystonic reactions (choice A) involve sudden and involuntary muscle contractions, which are not consistent with the client's symptoms. Bradykinesic side effects (choice B) refer to slowed movements, which are not present in this case. Extrapyramidal side effects (choice C) typically include symptoms like tremors, stiffness, and restlessness, but do not encompass the combination of symptoms seen in NMS.
In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurses priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others
- B. Anxiety related to sudden and abrupt lifestyle changes
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God
Correct Answer: A
Rationale: The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patients social isolation is important, but the risk for suicide has higher priority.
The main focus of medical management for anorexia is to:
- A. Encourage rapid weight gain.
- B. Encourage the client to eat voluntarily.
- C. Teach more appropriate food choices.
- D. None of the above.
Correct Answer: D
Rationale: The correct answer is D because the main focus of medical management for anorexia is not to encourage rapid weight gain, as it can lead to serious health complications. Encouraging the client to eat voluntarily is also not the main focus, as anorexia involves psychological factors that go beyond simple lack of appetite. Teaching more appropriate food choices is not the main focus either, as anorexia requires comprehensive treatment that addresses underlying emotional issues. Overall, the main focus is on a multidisciplinary approach that includes therapy, nutritional counseling, and medical monitoring to address the physical and psychological aspects of the disorder.