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A nurse is providing care for a patient with anorexia nervosa who has refused to eat. What is the nurse's priority intervention?
- A. Provide a structured meal plan and encourage the patient to eat.
- B. Allow the patient to skip meals to avoid overwhelming them.
- C. Focus on addressing body image concerns before eating.
- D. Monitor the patient's weight closely without intervention.
Correct Answer: A
Rationale: The correct answer is A: Provide a structured meal plan and encourage the patient to eat. This is the priority intervention because patients with anorexia nervosa often have a distorted perception of their body and food intake. By providing a structured meal plan, the nurse can help the patient establish a healthy eating routine. Encouraging the patient to eat is crucial to prevent further malnutrition and complications.
Choice B is incorrect because allowing the patient to skip meals can worsen their condition and reinforce unhealthy behaviors. Choice C is incorrect because addressing body image concerns should be done in conjunction with addressing the patient's nutritional needs. Choice D is incorrect because monitoring weight without intervening to address the underlying issue of refusal to eat is not sufficient in managing anorexia nervosa.
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A 19-year-old client is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The client sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the client's condition as:
- A. Altered mood states
- B. Disturbed thinking
- C. Social isolation
- D. Poor impulse control
Correct Answer: B
Rationale: The correct answer is B: Disturbed thinking. This is because the client's belief that her thoughts cause earthquakes and the world is burning indicates a break from reality, a hallmark of psychosis in schizophrenia. This demonstrates disorganized and illogical thinking, a key symptom of disturbed thinking. The other choices are incorrect because: A) Altered mood states typically refer to emotional disturbances, which are not the primary deficit in this scenario; C) Social isolation is a consequence of the client's symptoms but not the primary deficit; D) Poor impulse control is not the primary deficit in this case as the client's behavior is more indicative of disorganized thinking.
A client with borderline personality disorder is having difficulty with memories of sexual abuse. She has a history of suicidal gestures, self-mutilation, sexual addiction, and substance addiction. She complains of vague pains, menstrual problems, and headaches. She entered the partial hospital program to prevent another suicide gesture or self-mutilation. The nurse recognizes that collaborative therapy may be helpful for this client and knows that the most useful collaboration in this case would be the client, the nurse, and the:
- A. Occupational therapist exploring ways to reduce stress
- B. Physical therapist exploring ways to reduce back pain
- C. Acupuncturist exploring ways to reduce pain
- D. Sexologist exploring healthy sexuality and safe sex
Correct Answer: A
Rationale: The correct answer is A: Occupational therapist exploring ways to reduce stress. In the case of a client with borderline personality disorder experiencing trauma-related symptoms, such as memories of sexual abuse, the focus is on addressing underlying emotional issues and coping strategies. Collaborative therapy involving the client, nurse, and occupational therapist can be beneficial. The occupational therapist can help the client develop coping skills, manage stress, and improve daily functioning. This approach targets the root of the client's difficulties and provides holistic support.
Summary:
- Choice B (Physical therapist exploring ways to reduce back pain): This option does not directly address the client's primary concerns related to trauma and emotional distress.
- Choice C (Acupuncturist exploring ways to reduce pain): While pain management is important, it does not address the client's complex psychological needs and trauma history.
- Choice D (Sexologist exploring healthy sexuality and safe sex): While important in some cases, focusing solely on sexuality does not address the broader range of issues the client
A nurse is caring for a patient with bulimia nervosa. What should the nurse do to promote a healthy eating pattern?
- A. Provide a strict, rigid eating schedule without flexibility.
- B. Allow the patient to choose meals without any guidelines.
- C. Encourage regular meals and snacks with a focus on nutrition.
- D. Promote food restriction to avoid feelings of guilt after eating.
Correct Answer: C
Rationale: The correct answer is C because encouraging regular meals and snacks with a focus on nutrition helps stabilize blood sugar levels, reduce binge eating episodes, and promote overall health. This approach also supports the patient in developing a balanced relationship with food.
A: Providing a strict, rigid eating schedule may increase anxiety and reinforce unhealthy behaviors.
B: Allowing the patient to choose meals without guidelines may lead to erratic eating patterns and poor nutrition.
D: Promoting food restriction can exacerbate feelings of guilt and perpetuate the cycle of binge eating.
The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting?
- A. Lying to other patients
- B. Flattering the nursing staff
- C. Verbally abusing other patients
- D. Superficiality during counseling
Correct Answer: C
Rationale: The priority focus of limit setting should be on verbally abusing other patients (Choice C) because it directly harms others and creates a hostile environment. This behavior is not only detrimental to the well-being of other patients but also disrupts the therapeutic milieu. Limiting this behavior is crucial to ensure the safety and emotional health of all patients in the care setting. Lying to other patients (Choice A), flattering the nursing staff (Choice B), and being superficial during counseling sessions (Choice D) are concerning behaviors as well, but they do not pose an immediate risk to the safety and well-being of others in the same way that verbal abuse does. It is important to address all inappropriate behaviors, but the priority should be given to the behavior that has the most significant negative impact on the therapeutic environment.
The intervention of highest priority for a client with stage 3 Alzheimer's disease is to:
- A. Provide a stimulating environment
- B. Maintain hydration and nutrition
- C. Set limits on behavioral disinhibition
- D. Promote self-care activities
Correct Answer: B
Rationale: The correct answer is B because maintaining hydration and nutrition is crucial for the client's overall well-being and health in stage 3 Alzheimer's. Dehydration and malnutrition can lead to serious complications. Providing a stimulating environment (choice A) may be beneficial but not the highest priority. Setting limits on behavioral disinhibition (choice C) may be challenging due to the progression of the disease. Promoting self-care activities (choice D) may not be feasible as the client's cognitive abilities decline. Maintaining hydration and nutrition is essential for the client's survival and quality of life.