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A nurse is educating a patient with anorexia nervosa about nutrition. What should the nurse focus on?
- A. Encouraging rapid weight gain through a high-calorie diet.
- B. Promoting gradual weight gain and nutritional rehabilitation.
- C. Providing a low-calorie diet to maintain a healthy weight.
- D. Focusing on weight maintenance without discussing food intake.
Correct Answer: B
Rationale: The correct answer is B because promoting gradual weight gain and nutritional rehabilitation is essential in treating anorexia nervosa. Rapid weight gain can lead to medical complications and mental distress. Providing a low-calorie diet (C) contradicts the goal of weight gain. Focusing on weight maintenance without discussing food intake (D) neglects the importance of nutrition in recovery.
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A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. Appropriately express angry feelings.
- B. Verbalize two positive things about self.
- C. Verbalize the importance of eating a balanced diet.
- D. None of the above.
Correct Answer: D
Rationale: Rationale:
1. Patient's diagnosis indicates coping issues, not anger expression or self-esteem.
2. Patient's coping mechanism involves overeating and vomiting, not diet.
3. Outcome should focus on coping skills improvement, not unrelated goals.
4. None of the choices address the root issue of coping with loneliness and isolation.
5. Thus, the correct answer is D, as none of the options directly address the patient's ineffective coping mechanism.
Sudden temporary amnesia or instances of multiple personality are disorders
- A. dissociative
- B. anxiety
- C. psychotic
- D. schizophrenic
Correct Answer: A
Rationale: Dissociative disorders include amnesia and multiple personalities, linked to identity disruption.
A woman whose husband physically abuses her mentions to the nurse, 'Someday I'll have to leave him.' Which of the following would be the nurse's best response?
- A. Yes, you should, before he harms you badly.'
- B. Could we talk about developing a safety plan?'
- C. Are you afraid of what your family will say?'
- D. I don't know why you would stay with him.'
Correct Answer: B
Rationale: The correct answer is B: "Could we talk about developing a safety plan?" This response is the best choice as it acknowledges the woman's situation, offers support, and focuses on practical steps to ensure her safety. By suggesting a safety plan, the nurse is addressing the immediate concern of potential harm and empowering the woman to take control of her situation.
Incorrect Choices:
A: This response is too direct and may not take into account the complexities of the woman's situation. It lacks empathy and does not offer a constructive solution.
C: This response shifts the focus away from the woman's safety and onto external factors. It may come across as judgmental and unhelpful.
D: This response is dismissive and fails to acknowledge the seriousness of the situation. It does not offer any support or guidance to the woman in need.
An adolescent patient is diagnosed with dementia. The patient's age would cause a nurse to suspect which underlying condition sometimes associated with this diagnosis?
- A. Head trauma
- B. Neurosyphilis
- C. Pick disease
- D. Hypothyroidism
Correct Answer: A
Rationale: The correct answer is A: Head trauma. Adolescents are less likely to develop dementia due to age-related neurodegenerative diseases. Head trauma can lead to cognitive impairment and memory loss, mimicking symptoms of dementia. Neurosyphilis is a sexually transmitted infection affecting the brain, not common in adolescents. Pick disease is a rare neurodegenerative disorder more commonly seen in older adults. Hypothyroidism can cause cognitive symptoms but is not typically associated with dementia in adolescents.
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 family cares for her during the evening and at night. Noting the patient had several bruises, the nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage because she is confused and wanders all night. She says the bruises resulted from a fall down stairs. The daughter states, "I have lost my mother, and I cannot bear it anymore. It is wrecking my family."Â The nursing intervention that should take priority is:
- A. Teaching the daughter more about the effects of Alzheimer's disease.
- B. Identifying two options for caregiver respite and care assistance at night.
- C. Supporting the daughter to grieve the loss of her mother's ability to function.
- D. Teaching the family how to give physical care more effectively and efficiently.
Correct Answer: B
Rationale: The correct answer is B: Identifying two options for caregiver respite and care assistance at night. This is the priority intervention because it addresses the immediate need to ensure the patient's safety and well-being while also supporting the daughter who is struggling to cope. By identifying options for caregiver respite and care assistance at night, the daughter can get the help she needs to manage her mother's care effectively without feeling overwhelmed. This intervention promotes both the patient's safety and the daughter's mental well-being.
Choices A, C, and D are incorrect:
A: Teaching the daughter more about the effects of Alzheimer's disease. While education is important, in this scenario, the immediate need is to address caregiver respite and care assistance.
C: Supporting the daughter to grieve the loss of her mother's ability to function. While supporting the daughter emotionally is important, ensuring the patient's safety should take priority.
D: Teaching the family how to give physical care more effectively and efficiently. While this is important