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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Therapeutic nutrition begins for a patient with anorexia nervosa who is 70% of ideal body weight. Which nursing intervention is most important to add to the plan of care?
- A. Communicate empathy for the patient's feelings.
- B. Observe for adverse effects associated with refeeding.
- C. Teach patient about psychological origins of the disorder.
- D. Direct the patient to balance energy expenditure and caloric intake.
Correct Answer: B
Rationale: The correct answer is B: Observe for adverse effects associated with refeeding. This is important because refeeding syndrome can occur when a severely malnourished individual is reintroduced to nutrition too quickly, leading to potentially life-threatening electrolyte imbalances. Monitoring for signs such as fluid retention, electrolyte abnormalities, and changes in vital signs is crucial in preventing these complications.
Choice A: Communicating empathy is important in building trust and rapport with the patient, but it is not the most critical intervention in this scenario.
Choice C: Teaching the patient about the psychological origins of the disorder is important for long-term treatment, but it is not the most immediate concern when starting therapeutic nutrition.
Choice D: Directing the patient to balance energy expenditure and caloric intake is important for overall health, but it is not the priority when the patient is severely malnourished and at risk for refeeding syndrome.
Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness?
- A. Clubhouse model
- B. Cognitive Behavioral Therapy (CBT)
- C. Assertive Community Treatment (ACT)
- D. Cognitive Enhancement Therapy (CET)
Correct Answer: C
Rationale: Assertive Community Treatment (ACT) (C) offers 24/7 multidisciplinary support in the patient's environment, unlike the Clubhouse model (A), CBT (B), or CET (D), which lack such availability.
Which of the following is a common complication of anorexia nervosa?
- A. Hypertension and hyperglycemia.
- B. Cardiovascular instability and electrolyte imbalances.
- C. Insulin resistance and excessive weight gain.
- D. Severe dehydration and frequent urination.
Correct Answer: B
Rationale: The correct answer is B: Cardiovascular instability and electrolyte imbalances. Anorexia nervosa can lead to severe malnutrition, causing cardiovascular issues like low heart rate and blood pressure. Electrolyte imbalances occur due to inadequate nutrient intake. Hypertension and hyperglycemia (choice A) are not common in anorexia. Insulin resistance and weight gain (choice C) are more associated with conditions like obesity. Severe dehydration and frequent urination (choice D) are not typical manifestations of anorexia.
In Singapore, children and youth with disability in school age:
- A. Are rare at prevalence of less than 1%
- B. Receive services that are governed and funded by MSF only
- C. Are at higher risk of developing mental health conditions than typical children
- D. Need to have confirmed diagnosis before they can receive support in schools
Correct Answer: C
Rationale: School-age children with disabilities are at higher risk for mental health conditions due to social and functional challenges.
Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should
- A. develop an understanding of human sexual response.
- B. assess the patient's sexual functioning and needs.
- C. acquire knowledge of the patient's sexual roles.
- D. clarify own personal values about sexuality.
Correct Answer: D
Rationale: The correct answer is D because clarifying the nurse's own personal values about sexuality is crucial before addressing a patient's sexual dysfunction. By understanding personal biases or judgments, the nurse can provide unbiased care. Assessing the patient's needs (B) should follow, as it directly addresses the patient's concerns. Developing an understanding of human sexual response (A) is important, but not as urgent as addressing personal values. Acquiring knowledge of the patient's sexual roles (C) is less relevant and should come after understanding the patient's needs.