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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.
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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 nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group?
- A. Mild aerobic exercise
- B. Singing a song from World War II
- C. Discussing national leadership during the Vietnam War
- D. Identifying the most troubling story in today's newspaper
Correct Answer: C
Rationale: The correct answer is C. Discussing national leadership during the Vietnam War is most appropriate as it aligns with the reminiscence therapy goal of recalling past experiences to promote social interaction and cognitive stimulation. It is relevant to the age group of young-old adults who may have lived through that era, sparking meaningful discussions. Choice A does not directly relate to reminiscence therapy. Choice B may not resonate with all group members. Choice D focuses on negative news, which is not conducive to the therapeutic purpose.
A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively.
- A. Would you say your mood is often sad?
- B. Are you having any trouble with your memory?
- C. Have you noticed an increase in your alcohol use?
- D. Do you often experience moderate to severe pain?
Correct Answer: A
Rationale: The correct answer is A because assessing the patient's mood is crucial in detecting depression in the elderly. Depression is common in older adults and can often go undiagnosed. By asking about their mood, the nurse can identify potential signs of depression early on. Choices B, C, and D are incorrect as they do not directly relate to assessing depression. Memory issues (B) may indicate cognitive decline, increased alcohol use (C) could suggest substance abuse, and pain (D) may signal physical health concerns, but they are not specific indicators of depression in the elderly.
A patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented?
- A. Amenorrhea
- B. Alopecia
- C. Lanugo
- D. Stupor
Correct Answer: C
Rationale: The correct term to be documented is C: Lanugo. Lanugo is fine, downy hair that can cover a patient's body, often seen in newborns or individuals with certain medical conditions. In this case, the presence of lanugo indicates a potential underlying issue. Amenorrhea (A) refers to the absence of menstruation, not related to the hair. Alopecia (B) is hair loss, the opposite of lanugo. Stupor (D) is a state of reduced consciousness, not related to the hair condition described. Therefore, choice C is the correct answer as it directly matches the description given in the question.
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The nurse at the day care center noticed the patient was unkempt and had multiple bruises. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes I just cannot bear to care for her."Â Which nursing diagnosis would be most important to address for this patient?
- A. Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision
- B. Nonadherence related to confusion and disorientation, as evidenced by lack of cooperation
- C. Anxiety related to increasing disorientation, as evidenced by the patient wandering at night
- D. Impaired verbal communication related to brain impairment, as evidenced by the patient's confusion
Correct Answer: A
Rationale: The correct answer is A: Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision. The rationale is that the patient's Alzheimer's disease has led to impaired cognitive function, making her at risk for injury due to wandering and falls. The daughter's lack of supervision and inability to manage the patient's needs further exacerbate this risk. Choices B, C, and D are incorrect because they do not directly address the immediate safety concern of the patient being at risk for injury. Nonadherence, anxiety, and impaired communication are important issues but do not take precedence over the patient's safety in this context.