Nokea
A nursing intervention that will be planned to occur early in the nurse-patient relationship with a client with an eating disorder is:
- A. formulating a nurse-client contract.
- B. using confrontation to attack denial.
- C. placing the client in a therapeutic group.
- D. attacking enmeshment by separating client and family.
Correct Answer: A
Rationale: The correct answer is A: formulating a nurse-client contract. This intervention is essential early in the nurse-patient relationship with a client with an eating disorder because it establishes clear boundaries, roles, and expectations. By creating a contract, both the nurse and the client can communicate openly about their goals, responsibilities, and treatment plan. This helps build trust, promotes collaboration, and provides a framework for the therapeutic relationship.
Choices B, C, and D are incorrect:
B: Using confrontation to attack denial may be counterproductive and harmful in the early stages of the relationship as it can lead to resistance and damage trust.
C: Placing the client in a therapeutic group may be beneficial at a later stage but not necessarily an appropriate early intervention when individual needs should be addressed first.
D: Attacking enmeshment by separating client and family is not a suitable early intervention as it may cause distress and disrupt important support systems.
You may also like to solve these questions
A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this patient during the evening and night. Which type of facility should the nurse suggest to meet this patient's needs?
- A. Adult day care program
- B. Skilled nursing facility
- C. Partial hospitalization
- D. Group home
Correct Answer: A
Rationale: The correct answer is A: Adult day care program. This option is suitable as it provides supervision, safety, recreation, and social interaction during the day while allowing the family to care for the patient in the evening and night. Adult day care programs offer a structured environment with trained staff to ensure the patient's safety and provide social engagement.
- Option B, Skilled nursing facility, is not the best choice as it usually provides round-the-clock care, which may not be necessary in this case.
- Option C, Partial hospitalization, is more focused on intensive psychiatric treatment and therapy, which may not align with the patient's needs.
- Option D, Group home, is designed for individuals who need 24-hour care and supervision, which exceeds the patient's current requirements.
Which of the following assessments is most appropriate for a patient with anorexia nervosa?
- A. Monitor fluid intake exclusively.
- B. Check weight daily without discussing it with the patient.
- C. Observe the patient's response to meals, including food refusal or purging behavior.
- D. Monitor for signs of vitamin and mineral deficiencies.
Correct Answer: C
Rationale: The correct answer is C because observing the patient's response to meals, including food refusal or purging behavior, is crucial in assessing the patient's eating habits and behaviors associated with anorexia nervosa. This assessment helps in understanding the patient's relationship with food and identifying any disordered eating patterns. Monitoring fluid intake exclusively (Choice A) is not sufficient as it overlooks the broader aspects of the patient's eating behaviors. Checking weight daily without discussing it with the patient (Choice B) can be triggering and may not provide a comprehensive understanding of the patient's eating disorder. Monitoring for signs of vitamin and mineral deficiencies (Choice D) is important but does not directly address the specific behaviors associated with anorexia nervosa.
Treatment of communication disorders is normally the domain of speech therapists and related disciplines, and a range of successful treatment programmes and equipment are available for disabilities such as phonological disorder and stuttering (Saltuklaroglu & Kalinowski, 2005; Law, Garrett & Nye, 2004). For example, hand-held equipment can provide which of the following?
- A. Significant auditory feedback (SAF)
- B. Magnified auditory feedback (MAF)
- C. Altered auditory feedback (AAF)
- D. Actual auditory feedback (AAF)
Correct Answer: C
Rationale: Altered Auditory Feedback (AAF): A treatment for stuttering providing delayed auditory feedback or frequency changes to improve speech fluency.
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy."Â A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
- A. take the patient's vital signs.
- B. start intravenous fluids.
- C. administer a sedative.
- D. perform a mental status examination.
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.
- A. Anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. Relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. Neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. Agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: Anticholinergic toxicity. The patient's symptoms of restlessness, disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and significant departure from recent presentation are classic signs of anticholinergic toxicity. Anticholinergic medications can lead to central nervous system and peripheral anticholinergic effects, causing confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate initial interventions to address the symptoms.
Choices B, C, and D are incorrect because they do not align with the patient's symptoms and presentation. Choice B (Relapse of her psychosis) does not fully explain the physical symptoms such as hot and dry skin, dilated pupils, and disorientation. Choice C (Neuroleptic malignant syndrome) typically presents with muscle rigidity, hyperthermia, autonomic instability, and altered mental status, which are not completely consistent