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A nurse is working with a family with an elderly family member who is in the predisgnostic phase of Alzheimer disease. The most important nursing intervention at this time would be to provide:
- A. family consultation to facilitate communication.
- B. information about support groups and counseling.
- C. options directed toward the reduction of caregiver stress.
- D. educational materials that help them understand their situation.
Correct Answer: D
Rationale: The correct answer is D because educating the family about Alzheimer's disease in the predisgnostic phase helps them understand what to expect and how to cope effectively. This empowers them to make informed decisions and provide appropriate care. Option A focuses on communication, which is important but not the most critical intervention at this stage. Option B is helpful but may not address the family's immediate needs. Option C addresses caregiver stress, which is important but may not be the priority in the predisgnostic phase. Therefore, providing educational materials is the most important intervention to support the family during this phase.
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Which of the following is a characteristic of anorexia nervosa?
- A. Binge eating followed by purging.
- B. Refusal to maintain a healthy weight and an intense fear of gaining weight.
- C. Frequent overeating episodes without purging behaviors.
- D. Extreme preoccupation with body image and excessive exercise.
Correct Answer: B
Rationale: The correct answer is B because anorexia nervosa involves a refusal to maintain a healthy weight, an intense fear of gaining weight, and a distorted body image. This disorder is characterized by restrictive eating habits leading to significant weight loss. Individuals with anorexia nervosa often perceive themselves as overweight despite being underweight. Choices A, C, and D are incorrect as they describe characteristics more closely associated with bulimia nervosa, binge eating disorder, and orthorexia, respectively. Binge eating followed by purging (A) is a behavior seen in bulimia nervosa, frequent overeating episodes without purging (C) is typical of binge eating disorder, and extreme preoccupation with body image and excessive exercise (D) may be seen in orthorexia or other eating disorders, but not specifically in anorexia nervosa.
One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from:
- A. 150 to 102 pounds over a 4-month period.
- B. 120 to 90 pounds over a 3-month period.
- C. 130 to 100 pounds over a 2-month period.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the patient has experienced a significant weight drop from 150 to 102 pounds over a 4-month period. This represents a loss of 48 pounds over a relatively longer period, indicating a more severe and prolonged issue with weight loss. The other choices show weight drops of 30 pounds over 3 months (B) and 30 pounds over 2 months (C), which are also concerning but not as severe or long-lasting as the situation described in choice A. Choice D is incorrect as at least one patient should be admitted based on the information provided.
After assessing a patient with anorexia nervosa, a nurse writes the following nursing diagnosis: imbalanced nutrition, less than body requirements related to refusal to eat as evidenced by being 25% below body weight for height. The expected outcome should be listed as:
- A. Patient will identify cognitive distortions about food, weight, and body shape.'
- B. Patient will exhibit fewer signs of malnutrition within 2 weeks of hospitalization.'
- C. Patient will be able to describe both the physical and emotional complications of the eating disorder.'
- D. Patient will restore healthy eating patterns and normalize physiological parameters related to weight and nutrition.'
Correct Answer: D
Rationale: The correct answer is D because the expected outcome for a patient with imbalanced nutrition due to anorexia nervosa should focus on restoring healthy eating patterns and normalizing physiological parameters related to weight and nutrition. This outcome directly addresses the underlying issue of inadequate nutrition intake and helps the patient achieve a healthier state.
A: While identifying cognitive distortions is important for addressing the psychological aspects of anorexia nervosa, it does not directly address the patient's nutritional needs.
B: Exhibiting fewer signs of malnutrition is a vague outcome and does not specify how the patient will achieve this improvement.
C: Describing physical and emotional complications is informative but does not address the primary goal of improving nutrition intake and weight restoration.
After a person was abducted and raped at gunpoint by an unknown assailant, which trauma syndrome is most likely to occur?
- A. Decreased motor activity.
- B. Confusion and disbelief.
- C. Flashbacks and dreams.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Confusion and disbelief. After experiencing a traumatic event like abduction and rape at gunpoint, it is common for individuals to feel confused and in disbelief due to the overwhelming nature of the experience. This reaction is part of the acute stress response and is a normal psychological defense mechanism. Decreased motor activity (choice A) is less likely to be the immediate response to such a traumatic event. Flashbacks and dreams (choice C) are more characteristic of post-traumatic stress disorder (PTSD), which may develop later on but are not the initial trauma syndrome. Choice D is incorrect as trauma responses are expected in this situation.
The most severe psychological disorder is a(n)
- A. personality disorder
- B. psychosomatic illness
- C. anxiety disorder
- D. psychosis
Correct Answer: D
Rationale: Psychosis, involving severe reality distortion, is considered the most debilitating class of disorders.