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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 symptoms indicate severe malnutrition from self-starvation, leading to the yellow skin, cold extremities, low heart rate, and underweight status. The patient's statement reflects their distorted perception of body image and the extreme measures taken to achieve thinness. Choice A (Anxiety related to fear of weight gain) is not the best initial diagnosis as it focuses on anxiety rather than the critical issue of malnutrition. Choice B (Disturbed body image related to weight loss) is not the best initial diagnosis as it does not address the immediate risk of severe malnutrition. Choice C (Ineffective coping related to lack of conflict resolution skills) is not the best initial diagnosis as it does not prioritize the life-threatening malnutrition present in this case.
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A 17-year-old client who has anorexia nervosa states she believes she will have fewer problems in college and will be more popular if she continues to lose weight. What nursing intervention would be useful at this time?
- A. Assisting the client to identify the problems causing her concern.
- B. Determining what she hopes to gain from the behavior.
- C. Explaining that her chances for becoming ill from losing weight are high.
- D. Having a physical report sent to college officials indicating her condition.
Correct Answer: A
Rationale: The correct answer is A because it focuses on assisting the client to identify the problems causing her concern. By helping the client explore the underlying issues driving her desire to lose weight, the nurse can address the root cause of her behavior. This intervention promotes self-awareness and insight, enabling the client to better understand her motivations and make informed choices.
Option B is incorrect because while determining what the client hopes to gain from the behavior is important, it does not directly address the immediate concern of identifying underlying problems.
Option C is incorrect because simply explaining the risks of becoming ill may not effectively address the client's belief that losing weight will lead to fewer problems and increased popularity.
Option D is incorrect because sending a physical report to college officials without the client's consent may violate confidentiality and trust, and it does not address the client's psychological needs.
The client is hostile, angry, and suspicious. He thinks that the staff is trying to poison him. He is classified as:
- A. Paranoid
- B. Catatonic
- C. Disorganized
- D. Undifferentiated
Correct Answer: A
Rationale: The correct answer is A: Paranoid. This client's behavior aligns with paranoid schizophrenia symptoms, characterized by hostility, anger, suspicion, and delusions of persecution like being poisoned. Catatonic schizophrenia (B) involves motor disturbances, disorganized schizophrenia (C) features disorganized speech and behavior, and undifferentiated schizophrenia (D) includes a mix of symptoms without fitting a specific subtype. Paranoid schizophrenia best fits the client's presentation based on the described symptoms.
A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2G sodium diet, Restraint as needed, Limit fluids to 1800~mL daily, Continue antihypertensive medication, Milk of magnesia 30~mL PO once if no bowel movement for 3 days. The nurse should:
- A. question the fluid restriction
- B. question the order for restraint
- C. transcribe the prescriptions as written
- D. assess the residents bowel elimination
Correct Answer: B
Rationale: Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.
The mother of a 2-year-old tells the nurse at the well-child clinic that her child likes to take a blanket wherever he goes. The mother asks if she should take the blanket away from the child. The nurse counsels the mother to allow the child to have the blanket because it reminds him of his mother and comforts him. The basis for this counseling is:
- A. Mahler's theory of object relations
- B. Freud's developmental theory
- C. Kernberg's conceptualization object constancy
- D. Sullivan's theory of 'good me'
Correct Answer: A
Rationale: The correct answer is A: Mahler's theory of object relations. Mahler emphasizes the importance of transitional objects like a blanket for young children to provide comfort and security as they develop a sense of self and separation from their primary caregiver. This theory aligns with the situation described, where the child's attachment to the blanket symbolizes the bond with the mother.
Explanation for why the other choices are incorrect:
B: Freud's developmental theory focuses on psychosexual stages and the role of unconscious processes, not specifically on transitional objects.
C: Kernberg's conceptualization of object constancy pertains to personality disorders and object relations in adult psychotherapy, not child development.
D: Sullivan's theory of 'good me' is about interpersonal relationships and self-esteem, not directly related to transitional objects in child development.
A 72-year-old widow has just returned home after 2 weeks in the hospital after a fall. She lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the visiting nurse stopped by 2 days after discharge, he found the woman confused and disoriented, with an unsteady gait. The patient asks him who he is and why he is there. The nurse correctly deduces that the most likely cause for the changes seen in the patient is:
- A. Delirium.
- B. Dementia.
- C. Drug toxicity.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Delirium. The patient's sudden onset of confusion, disorientation, and unsteady gait after discharge from the hospital suggests delirium. Delirium is an acute change in mental status with fluctuating symptoms, often caused by underlying medical conditions, medications (such as diazepam), or environmental factors. In this case, the recent hospitalization, multiple medications, and potential stressors like living alone and recent fall increase the risk for delirium.
Incorrect choices:
B: Dementia is a chronic, progressive condition characterized by memory loss and cognitive decline. The sudden onset of symptoms in this case is not consistent with dementia.
C: Drug toxicity could be a possibility given the patient's medication list, but delirium is a more likely explanation due to the acute onset of symptoms post-hospitalization.
D: None of the above is incorrect because delirium is the most likely cause based on the patient's presentation and risk factors.