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A nurse is caring for a patient with bulimia nervosa who is experiencing frequent purging. What is a priority assessment?
- A. Monitor electrolyte levels and cardiac function.
- B. Observe for signs of dehydration and low blood pressure.
- C. Assess for any compulsive exercise behaviors.
- D. Monitor for changes in eating patterns and food preferences.
Correct Answer: A
Rationale: The correct answer is A, to monitor electrolyte levels and cardiac function. This is a priority assessment because frequent purging in bulimia nervosa can lead to electrolyte imbalances and cardiac complications, such as arrhythmias and heart failure. Monitoring these parameters is crucial for early detection and intervention to prevent serious health consequences. Observing for signs of dehydration and low blood pressure (Choice B) is important but not as critical as monitoring electrolyte levels and cardiac function. Assessing for compulsive exercise behaviors (Choice C) and monitoring changes in eating patterns and food preferences (Choice D) are also relevant but secondary to the immediate risk of electrolyte imbalances and cardiac issues.
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A 34-year-old client with residual schizophrenia frequently displays ambivalence. The community mental health nurse suggests that a realistic short-term outcome for this client problem is that client will:
- A. Decide his or her own daily schedule
- B. Refuse to attend activities
- C. Choose which clinic staff member to work with
- D. Choose between two outfits to wear each morning
Correct Answer: D
Rationale: The correct answer is D: Choose between two outfits to wear each morning. This outcome is realistic because it focuses on a concrete and manageable task that the client can achieve, promoting independence and decision-making skills. It also addresses the issue of ambivalence by providing the client with limited choices, which can help reduce anxiety and facilitate decision-making.
A: Decide his or her own daily schedule - This option may be too overwhelming for a client with residual schizophrenia and may not directly address the issue of ambivalence.
B: Refuse to attend activities - This option is negative and does not promote progress or independence for the client.
C: Choose which clinic staff member to work with - This option may not be directly related to the client's ambivalence or daily functioning, making it less relevant as a short-term goal.
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
- A. Are you thinking of harming yourself?
- B. It will take time, but you will feel the same.
- C. Your friends will understand when you explain it was not your fault.
- D. You will be able to find meaning in this experience as time goes on.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.
In Avoidant/Restrictive Food Intake Disorder (ARFID), which of the following is a characteristic clinical feature?
- A. Do not prefer foods with strong smells
- B. Do not prefer bland foods
- C. Do not have weight concerns
- D. Do not prefer solid foods
Correct Answer: C
Rationale: ARFID involves food avoidance without body image concerns, unlike AN; lack of weight concerns is a key feature per DSM-5.
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style."Â The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?
- A. Eating disorder not otherwise specified
- B. Anorexia nervosa
- C. Bulimia nervosa
- D. Binge eating
Correct Answer: B
Rationale: The correct answer is B: Anorexia nervosa. This diagnosis fits the patient's symptoms of restrictive eating, significant weight loss, amenorrhea, and denial of the severity of the situation. The patient's behavior of cooking gourmet meals but eating tiny portions and wearing layers of clothes to hide weight loss are classic signs of anorexia nervosa. The other choices are incorrect because:
A: Eating disorder not otherwise specified does not fully capture the severity and specific symptoms exhibited by the patient.
C: Bulimia nervosa involves binge-eating followed by compensatory behaviors, which are not described in the scenario.
D: Binge eating disorder involves recurrent episodes of binge eating without compensatory behaviors, which is not indicated.
An elderly woman is brought to the clinic by her daughter. The client states that she has had a cold for several days. Her daughter states that her mother has been confused about when her routine medications are to be taken and that her mother has never experienced confusion before. Based on this information, it is important that the nurse ask the client whether:
- A. There is a history of mental illness in the family.
- B. She has been given a diagnosis of a mental health disorder in the past.
- C. She can recall her last visit to a physician.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: There is a history of mental illness in the family. This is important because the sudden onset of confusion in an elderly person could be indicative of a new mental health issue or cognitive decline. Asking about a family history of mental illness can provide valuable insights into potential genetic predispositions or underlying conditions that may be contributing to the client's confusion.
Choices B and C are incorrect because the client's own history of mental health diagnosis or ability to recall a physician visit are not directly related to the sudden onset of confusion. Choice D is incorrect because asking about a family history of mental illness could provide crucial information in understanding the client's current condition.