Nokea
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.
You may also like to solve these questions
A woman, abducted and raped at gunpoint by an unknown assailant, was found confused and disoriented. The nurse makes these observations about the patient: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the patient's level of anxiety?
- A. Weak
- B. Mild
- C. Moderate
- D. Severe
Correct Answer: D
Rationale: The correct answer is D: Severe. The patient's symptoms of talking rapidly, inability to concentrate, and indecisiveness are indicative of severe anxiety. Rapid speech and disjointed phrases suggest heightened arousal, while the inability to concentrate and make decisions point to severe impairment in cognitive functioning. These symptoms align with the DSM-5 criteria for severe anxiety, which includes extreme levels of distress and impairment in daily functioning. Weak (A), mild (B), and moderate (C) levels of anxiety would not typically manifest in such severe cognitive and behavioral symptoms.
A patient reports, 'My brain is tapped. The government has implanted a device in my head.' What outcome would the nurse identify as being appropriate for the patient to achieve within 1 week of admission?
- A. Taking antipsychotic medication as prescribed without objection
- B. Giving coherent data to support beliefs that the brain is 'tapped'
- C. Interpreting reality correctly by stating no 'brain tap' has been implanted
- D. Reporting feeling less anxious about having the government listening to interior thoughts
Correct Answer: C
Rationale: The correct answer is C because it reflects the goal of promoting reality testing and challenging the patient's delusional beliefs. By helping the patient interpret reality correctly and recognize that the implanted device is not real, the nurse can support the patient in overcoming their delusions and improving their mental health.
Choice A is incorrect as simply taking medication does not address the underlying delusional belief. Choice B is incorrect as it validates and reinforces the patient's delusion, which is not therapeutic. Choice D is incorrect as it does not address the core issue of the patient's delusional belief and may not lead to long-term improvement in mental health.
A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
- A. Remotivation
- B. Activity group
- C. Psychotherapy
- D. Reminiscence (life review)
Correct Answer: A
Rationale: Remotivation therapy helps to resocialize regressed and apathetic patients by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work and hobbies related to the topic. Group leaders give members acceptance and appreciation. Group psychotherapy would not be effective for this patient. An activity group does not address the patients problem.
Select the best comment for a nurse to begin an interview with an elderly patient.
- A. I am a nurse. Are you familiar with what nurses do?
- B. Hello. I am going to ask you some questions to get to know you better.
- C. You look comfortable and ready to participate in an admission interview. Shall we get started?
- D. Hello. My name is_____ and I am a nurse. How you would like to be addressed by staff?
Correct Answer: D
Rationale: The correct answer is D because it establishes the nurse's identity and shows respect by asking the patient's preference for addressing them. This approach sets a positive tone and promotes patient-centered care. Option A is incorrect as it assumes the patient's familiarity with nurses. Option B lacks professionalism and fails to acknowledge the purpose of the interview. Option C assumes the patient's readiness without confirming it directly and may come off as presumptuous.
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.