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A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, "I will not eat until I lose enough weight to look thin." Select the best initial nursing diagnosis.

  • A. Anxiety related to fear of weight gain
  • B. Disturbed body image related to weight loss
  • C. Ineffective coping related to lack of conflict resolution skills
  • D. Imbalanced nutrition: less than body requirements related to self-starvation
Correct Answer: D

Rationale: The correct initial nursing diagnosis is D: Imbalanced nutrition: less than body requirements related to self-starvation. The patient's presentation of yellow skin, cold extremities, bradycardia, low weight, and refusal to eat indicate severe malnutrition due to self-starvation. The key indicators are the physical signs of malnutrition and the patient's statement about not eating until they lose enough weight. Options A and B do not address the primary issue of malnutrition and self-starvation. Option C focuses on coping skills, which is not the priority in this case. Therefore, option D is the best initial nursing diagnosis to address the patient's life-threatening condition of malnutrition.

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Which expectation should be considered most critical prior to discharging a client with anorexia nervosa from the hospital?

  • A. Attainment of minimum normal weight.
  • B. Resumption of normal menstrual cycle.
  • C. Knowledge of caloric and nutritional value of foods required for a balanced diet.
  • D. Reduction of periods of active exercise to three times daily.
Correct Answer: A

Rationale: Rationale: A critical expectation before discharging a client with anorexia nervosa is the attainment of minimum normal weight. This is crucial for the client's physical health and to prevent complications like organ damage. Resuming a normal menstrual cycle (B) is important but not as critical as restoring weight. Knowing about nutrition (C) is valuable but not as urgent as weight gain. Reducing exercise (D) may be necessary, but weight restoration takes precedence for overall health.

Which symptom reported by a client, age 35, who was sexually abused as a child reflects the diagnosis of posttraumatic stress disorder (PTSD)?

  • A. Reexperiencing the traumatic event
  • B. Refusing to go to public places from which escape may be difficult
  • C. Seeking advice and guidance prior to making any significant decision
  • D. Ruminating over the abuse with friends and acquaintances
Correct Answer: A

Rationale: The correct answer is A: Reexperiencing the traumatic event. This symptom is a key criterion for diagnosing PTSD according to the DSM-5. It includes flashbacks, nightmares, or intrusive thoughts related to the traumatic event. This symptom indicates that the client is experiencing distressing memories of the past abuse, which is a common feature of PTSD.

Choice B is incorrect because it describes agoraphobia, a separate anxiety disorder, not specific to PTSD. Choice C is incorrect as seeking advice is not a diagnostic criterion for PTSD. Choice D is incorrect because ruminating over the abuse with others may reflect coping mechanisms or seeking support, but it does not necessarily indicate PTSD.

The medication donepezil (Aricept) frequently is used to treat the early-stage symptoms of Alzheimer's disease. When administering this particular medication, the nurse should be especially alert to assess the client for:

  • A. Weight changes
  • B. Tremors
  • C. Increased sweating
  • D. Alterations in blood pressure
Correct Answer: D

Rationale: The correct answer is D: Alterations in blood pressure. Donepezil can cause changes in blood pressure as a side effect. Nurses should monitor for orthostatic hypotension and changes in blood pressure to prevent adverse effects. Weight changes (A), tremors (B), and increased sweating (C) are not commonly associated with donepezil and are less likely to be significant concerns when administering this medication for Alzheimer's disease.

When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?

  • A. Evidence of spasticity or flaccidity
  • B. The patients level of motor activity
  • C. Medications the patient has recently taken
  • D. Level of preoccupation with somatic symptoms
Correct Answer: C

Rationale: Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.

What is an appropriate goal for a nurse working with a patient with anorexia nervosa?

  • A. The patient will gain weight rapidly to restore nutritional balance.
  • B. The patient will express satisfaction with their body image by the end of treatment.
  • C. The patient will eat three meals daily and demonstrate healthy eating behaviors.
  • D. The patient will be able to resume normal physical activities without fatigue.
Correct Answer: C

Rationale: The correct answer is C because setting a goal for the patient to eat three meals daily and demonstrate healthy eating behaviors is a more realistic and achievable target for someone with anorexia nervosa. This goal focuses on establishing regular eating habits and promoting a healthy relationship with food, which are crucial in the treatment of anorexia nervosa. Choices A and D are incorrect as rapid weight gain and resuming normal physical activities may not be safe or sustainable goals for someone with anorexia nervosa. Choice B is also incorrect because body image satisfaction is a complex issue that may not be directly addressed solely through treatment for anorexia nervosa.

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