Nokea
A nurse is caring for a patient diagnosed with anorexia nervosa. What is the most important intervention during the refeeding phase?
- A. Monitor weight gain and provide a structured meal plan.
- B. Encourage the patient to eat independently without supervision.
- C. Focus on psychological therapy to address emotional issues.
- D. Offer the patient high-calorie, high-fat foods to increase intake.
Correct Answer: A
Rationale: The correct answer is A because during the refeeding phase of anorexia nervosa, monitoring weight gain and providing a structured meal plan are crucial to prevent refeeding syndrome and ensure a safe and gradual increase in caloric intake. This approach helps prevent complications such as electrolyte imbalances and organ dysfunction. Encouraging the patient to eat independently without supervision (B) can be harmful as they may not consume adequate or balanced nutrition. Psychological therapy (C) is important but not the most crucial during the refeeding phase. Offering high-calorie, high-fat foods (D) can lead to rapid weight gain and further complications.
You may also like to solve these questions
Which of the following is a priority nursing intervention for a patient with anorexia nervosa during the refeeding process?
- A. Encourage the patient to engage in physical activity to stimulate appetite.
- B. Monitor vital signs and electrolyte levels to avoid refeeding syndrome.
- C. Offer high-calorie snacks to speed up weight gain.
- D. Focus on the patient's body image concerns before addressing nutrition.
Correct Answer: B
Rationale: The correct answer is B because monitoring vital signs and electrolyte levels is crucial during the refeeding process to prevent refeeding syndrome, a potentially life-threatening complication. This intervention ensures early detection of any electrolyte imbalances or cardiac complications that may arise as the body readjusts to increased food intake. Encouraging physical activity (A) can be harmful due to the patient's compromised state. Offering high-calorie snacks (C) may lead to rapid weight gain and increase the risk of refeeding syndrome. Focusing on body image concerns (D) is important but should not take precedence over addressing the patient's immediate medical needs.
A patient who has been taking fluoxetine (Prozac) 60 mg daily for the past 6 months tells the nurse at the medication follow-up clinic that he is considering stopping the Prozac. He states his mood is fine, and now that he is living normally, his wife is concerned that he has no sex drive. Which response would be best?
- A. Without the medicine the depression will likely return; you and your wife will need to adjust to the sexual side effects.
- B. If we switch your medication time to the morning, the sexual side effects will be worn off in time for evening sexual activity.
- C. The problem is not likely due to the medicine. Often the depression itself, even after it improves, continues to dampen sex drive.
- D. Without an antidepressant, the depression is more likely to reoccur, but there are other medications that do not interfere so much with sex.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Correctly acknowledges the patient's concern about sexual side effects.
2. Highlights the importance of managing depression to prevent recurrence.
3. Offers a solution by mentioning alternative medications with less impact on sex drive.
4. Empowers the patient by providing information and options for treatment.
5. Addresses both the patient's current situation and long-term mental health needs.
Summary of why other choices are incorrect:
A: Overlooks the patient's valid concern about sexual side effects and lacks a proactive solution.
B: Focuses on timing of medication without addressing the underlying issue of sexual side effects.
C: Dismisses the patient's concern and fails to provide a solution or alternative options.
An elderly patient with dementia paces the hallway and often engages in wandering. The nurse documents that the patient is exhibiting which type of behavior that is characteristic of dementia?
- A. Passive behavior
- B. Functionally impaired behavior
- C. Involuntary psychomotor behavior
- D. Nonaggressive psychomotor behavior
Correct Answer: D
Rationale: The correct answer is D: Nonaggressive psychomotor behavior. In dementia, wandering and pacing are common behaviors due to cognitive impairment. Nonaggressive behavior refers to actions that do not involve harm or aggression towards others. The patient's behavior is voluntary and purposeless, indicating psychomotor involvement. Choices A, B, and C do not accurately describe the behavior exhibited by the patient with dementia. Passive behavior implies lack of engagement, functionally impaired behavior suggests difficulty performing activities of daily living, and involuntary psychomotor behavior implies actions beyond the patient's control, which are not the case in this scenario.
Which assessment findings would be expected for a patient diagnosed with bipolar I disorder?
- A. Rapid cycling
- B. Major depression and acute mania
- C. Major depression and/or hypomania
- D. Hypomania and/or minor depression
Correct Answer: B
Rationale: Step 1: Bipolar I disorder involves episodes of acute mania, which is characterized by elevated mood, increased energy, and impulsivity.
Step 2: Major depression can also occur in bipolar I, as patients may experience depressive episodes.
Step 3: Therefore, choice B (Major depression and acute mania) is the correct answer.
Summary: Choice A is incorrect because rapid cycling refers to frequent mood shifts, not specific to bipolar I. Choice C is incorrect as hypomania is characteristic of bipolar II, not bipolar I. Choice D is incorrect as minor depression is not a typical feature of bipolar I disorder.
A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget."Â What is the patient's present coping strategy?
- A. Somatization
- B. Repression
- C. Projection
- D. Denial
Correct Answer: D
Rationale: The correct answer is D: Denial. The patient's statement of "I can't talk about it. Nothing happened. I have to forget" indicates a denial coping strategy. Denial is a defense mechanism where individuals refuse to acknowledge a stressful situation or event. In this case, the patient is attempting to block out the traumatic experience of being abducted and raped by denying its existence. This coping mechanism helps the individual temporarily avoid the emotional distress associated with the event.
A: Somatization involves expressing emotional distress through physical symptoms, which is not evident in the patient's statement.
B: Repression is the unconscious blocking of unpleasant memories, whereas the patient is consciously trying to forget the event.
C: Projection involves attributing one's own thoughts or feelings to others, which is not demonstrated in the patient's statement.
In summary, the patient's use of denial as a coping strategy is evident in their attempt to minimize the traumatic experience by refusing to acknowledge it.