Nokea
A patient was admitted in a semistuporous catatonic state. Family states that the patient has neither left the apartment nor attended to personal hygiene for several weeks. The patient's last 48 hours have been spent lying in bed, mute and motionless. The nursing diagnosis that should be considered the priority is:
- A. self-care deficit.
- B. situational low self-esteem.
- C. disturbed thought processes.
- D. impaired verbal communication.
Correct Answer: A
Rationale: The correct answer is A: self-care deficit. The patient's symptoms indicate a lack of ability to perform self-care activities, which poses a risk to their health and well-being. This is a priority as addressing this issue will directly impact the patient's physical health and overall functioning. Situational low self-esteem (B) is not the priority as it focuses on the patient's emotional state rather than their immediate physical needs. Disturbed thought processes (C) and impaired verbal communication (D) may be present but are not the priority over the patient's inability to perform self-care activities.
You may also like to solve these questions
During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (SHT2) excess will suggest that the client receive:
- A. Haloperidol (Haldol)
- B. Chlorpromazine (Thorazine)
- C. Olanzapine (Zyprexa)
- D. Phenelzine (NardiI)
Correct Answer: C
Rationale: Rationale: Olanzapine (Zyprexa) is the correct choice because it is an atypical antipsychotic that targets serotonin receptors, particularly 5-HT2 receptors known to be involved in negative symptoms of schizophrenia like apathy, avolition, and blunted affect. Olanzapine's mechanism of action helps alleviate these symptoms by modulating serotonin levels in the brain.
Incorrect Choices:
A: Haloperidol and B: Chlorpromazine are typical antipsychotics that primarily target dopamine receptors and are less effective in treating negative symptoms associated with schizophrenia.
D: Phenelzine is a monoamine oxidase inhibitor used to treat depression and anxiety disorders, not schizophrenia symptoms related to serotonin excess.
A patient with bulimia nervosa expresses that they feel better after purging. How should the nurse respond?
- A. Encourage the patient to continue purging to maintain weight.
- B. Explain that purging has long-term harmful effects on the body.
- C. Agree that purging can help with weight control and self-esteem.
- D. Tell the patient that purging is an effective method to prevent weight gain.
Correct Answer: B
Rationale: The correct answer is B because purging in bulimia nervosa is a maladaptive behavior with severe health consequences. The nurse should educate the patient about the long-term harmful effects of purging, such as electrolyte imbalances, dental issues, and organ damage. Encouraging the patient to continue purging (A) reinforces the harmful behavior. Agreeing with the patient (C) or suggesting purging as an effective weight management method (D) further perpetuates the unhealthy behavior and fails to address the underlying issues. Overall, educating the patient about the risks of purging is essential in promoting recovery and better health outcomes.
The male manager of a health club placed a hidden video camera in the women's locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is
- A. homosexuality.
- B. exhibitionism.
- C. pedophilia.
- D. voyeurism.
Correct Answer: D
Rationale: The correct answer is D: voyeurism. Voyeurism is a disorder characterized by the act of observing an unsuspecting individual who is naked, in the process of undressing, or engaging in sexual activity, for the purpose of sexual gratification. In this scenario, the male manager is surreptitiously recording women in the locker room without their consent, indicating voyeuristic behavior.
A: Homosexuality is the sexual orientation of being attracted to individuals of the same gender and is not relevant to the scenario.
B: Exhibitionism involves exposing one's genitals to others for sexual gratification, which is not the case in this scenario.
C: Pedophilia is a disorder characterized by an adult's sexual interest in prepubescent children, which is not applicable in this scenario.
In summary, the behavior of the male manager aligns with voyeurism due to the secret recording of women in the locker room for sexual gratification.
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.
What behavior signals that a nurse caring for a patient with bulimia nervosa is experiencing rescue feelings? The nurse:
- A. Makes nonjudgmental comments.
- B. Refers the patient to a self-help group for persons with eating disorders.
- C. Teaches the patient about signs of increased anxiety and ways to intervene.
- D. Determines the patient has poor eating habits and provides a diet to follow.
Correct Answer: D
Rationale: The correct answer is D because providing a diet to follow indicates a rescuer mentality, where the nurse is assuming the role of fixing the patient's eating habits without addressing the underlying emotional issues. A, B, and C focus on supportive and empowering approaches which are more appropriate for helping the patient with bulimia nervosa.