Nokea
A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is 2.7 mg/dL. Which nursing diagnosis applies?
- A. Adult failure to thrive related to abuse of laxatives, as evidenced by electrolyte imbalances and weight loss
- B. Ineffective health maintenance related to self-induced vomiting, as evidenced by swollen parotid glands and hyperkalemia
- C. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake, as evidenced by weight loss and hyperkalemia
- D. Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia.
Rationale:
1. Anorexia nervosa involves severe restriction of food intake, leading to significant weight loss and malnutrition.
2. The patient's history of virtually stopping eating and losing 25% of body weight aligns with the nursing diagnosis of imbalanced nutrition.
3. Hypokalemia (low serum potassium level) is common in patients with anorexia nervosa due to inadequate intake or purging behaviors.
4. The other choices are incorrect because they do not match the patient's specific presentation of anorexia nervosa and hypokalemia.
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Which instruction has priority when teaching a patient taking clozapine (Clozaril)?
- A. Avoid unprotected sex.
- B. Report sore throat and fever immediately.
- C. Reduce foods high in polyunsaturated fats.
- D. Use over-the-counter preparations for rashes.
Correct Answer: B
Rationale: The correct answer is B: Report sore throat and fever immediately. This is because clozapine can cause a serious condition called agranulocytosis, which is characterized by a dangerously low white blood cell count. Sore throat and fever can be early signs of this condition, so it is crucial to report them immediately to prevent serious complications.
Avoiding unprotected sex (choice A) is important for overall health but is not directly related to clozapine use. Reducing foods high in polyunsaturated fats (choice C) is not a priority as it does not impact the safety or effectiveness of clozapine. Using over-the-counter preparations for rashes (choice D) is not advised as rashes can be a side effect of clozapine, and professional medical advice should be sought.
In activity 5, all of the following people got sick from the concession stand except
- A. Jose
- B. Lisa
- C. Mia
- D. Ken
Correct Answer: D
Rationale: Assuming Ken did not get sick (context-specific), he is the exception among those listed.
A client has been diagnosed with Alzheimer's disease, stage 1. The nurse would expect to help the family plan measures to assist the client with:
- A. Recent memory loss
- B. Catastrophic reactions
- C. Progressive gait disturbances
- D. Perseveration
Correct Answer: A
Rationale: The correct answer is A: Recent memory loss. In stage 1 of Alzheimer's disease, the primary symptom is mild memory loss, particularly with recent events and information. The nurse would help the family plan measures to assist the client by implementing strategies to support memory, such as setting reminders, organizing daily routines, and using memory aids. Choice B, catastrophic reactions, is more commonly associated with later stages of the disease. Choice C, progressive gait disturbances, is not a typical symptom of stage 1 Alzheimer's. Choice D, perseveration, involves the repetition of a particular response or behavior and is not a primary concern in stage 1 Alzheimer's disease.
What is the most effective strategy for preventing relapse in patients with anorexia nervosa?
- A. Providing a strict, rigid meal plan that the patient must follow.
- B. Offering frequent, supportive counseling to address underlying issues.
- C. Encouraging the patient to self-monitor their food intake only.
- D. Reassuring the patient that their weight will stabilize without further intervention.
Correct Answer: B
Rationale: The correct answer is B because offering frequent, supportive counseling to address underlying issues is the most effective strategy for preventing relapse in patients with anorexia nervosa. Counseling helps patients explore and work through the root causes of their disorder, such as body image issues, low self-esteem, or past trauma. It also provides ongoing support and guidance in developing healthy coping mechanisms and behaviors.
Choice A is incorrect because providing a strict, rigid meal plan can exacerbate feelings of control and restriction, which are common triggers for relapse in individuals with anorexia nervosa.
Choice C is incorrect as solely focusing on self-monitoring food intake may not address the psychological and emotional factors contributing to the disorder, which are crucial for long-term recovery.
Choice D is incorrect because reassuring the patient that their weight will stabilize without further intervention ignores the complexities of anorexia nervosa and does not address the underlying issues that need to be resolved for sustained recovery.
What is the primary nursing concern for a patient with anorexia nervosa during the early stages of treatment?
- A. Ensuring rapid weight gain to restore health.
- B. Addressing the patient's psychological issues related to body image.
- C. Maintaining nutritional intake to prevent further weight loss.
- D. Promoting self-esteem and body image satisfaction.
Correct Answer: C
Rationale: The primary nursing concern for a patient with anorexia nervosa in the early stages of treatment is maintaining nutritional intake to prevent further weight loss. This is crucial as malnutrition can lead to serious health complications. Ensuring adequate nutrition supports physical health and provides a foundation for addressing psychological issues in later stages of treatment. Rapid weight gain (A) can be harmful and lead to refeeding syndrome. Addressing psychological issues (B) and promoting self-esteem (D) are important but secondary concerns once nutritional stability is achieved.