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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.
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schizophrenia usually involves delusions of persecution and grandeur
- A. Catatonic
- B. Disorganized
- C. Paranoid
- D. Undifferentiated
Correct Answer: C
Rationale: Paranoid schizophrenia is marked by prominent delusions of persecution or grandeur.
What is the primary goal for a nurse treating a patient with anorexia nervosa?
- A. To help the patient achieve optimal body weight quickly.
- B. To restore the patient's nutritional balance and weight.
- C. To involve the patient in daily exercise routines to improve physical health.
- D. To encourage the patient to undergo intensive psychotherapy.
Correct Answer: B
Rationale: The primary goal for a nurse treating a patient with anorexia nervosa is to restore the patient's nutritional balance and weight. This is because individuals with anorexia nervosa often have severe malnutrition and weight loss, which can lead to serious health complications. By focusing on restoring nutritional balance and weight, the nurse can help improve the patient's physical health and overall well-being. Encouraging the patient to achieve optimal body weight quickly (choice A) may not be realistic or safe, as rapid weight gain can have negative consequences. Involving the patient in daily exercise routines (choice C) may exacerbate the patient's compulsive behaviors around food and exercise. Encouraging the patient to undergo intensive psychotherapy (choice D) is important, but it is not the primary goal in the initial treatment of anorexia nervosa.
An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
- A. The patient's vital signs
- B. Consent signed by the patient
- C. Supervision and credentials of the examiner
- D. Storage location of the patient's personal effects
Correct Answer: B
Rationale: The correct answer is B: Consent signed by the patient. This is crucial as it ensures the patient's autonomy and willingness to undergo evidence collection. Without proper consent, the procedure would be unethical and potentially illegal. Vital signs (A) may be important for overall assessment but are not directly related to evidence collection. Supervision and credentials of the examiner (C) are necessary but not the most important documentation. The storage location of personal effects (D) is relevant for patient safety but not essential for evidence collection.
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." 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 diagnosis is B: Anorexia nervosa. This patient exhibits key symptoms such as restrictive eating leading to significant weight loss, wearing layers of clothing to hide body shape, and amenorrhea. These symptoms align with the diagnostic criteria for anorexia nervosa. The other choices are incorrect because they do not fully capture the combination of symptoms present in this case. Choice A (Eating disorder not otherwise specified) is too broad and does not specify the severity of the symptoms. Choice C (Bulimia nervosa) typically involves binge eating followed by compensatory behaviors, which is not indicated in this case. Choice D (Binge eating) focuses solely on overeating without the restrictive eating and weight loss seen in anorexia nervosa.
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse identifies which of the following nursing diagnosis for the client?
- A. Disturbed thought processes
- B. Powerlessness
- C. Ineffective coping
- D. Defensive coping
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This nursing diagnosis is appropriate because the client's symptoms suggest cognitive impairment and delusions, which are common in dementia. The client's accusations of theft and imprisonment indicate a distortion in reality perception, reflecting disturbed thought processes. Powerlessness (B) relates more to lack of control over circumstances, not cognitive issues. Ineffective coping (C) and Defensive coping (D) focus on emotional responses rather than cognitive impairment.