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A patient with anorexia nervosa in outpatient treatment has begun refeeding. Between the first and second appointment, the patient gained 8 pounds. The nurse should:
- A. Praise the weight gain.
- B. Assess lung sounds and extremities.
- C. Suggest implementation of an exercise program.
- D. Establish a higher target for weight gain for the next week.
Correct Answer: B
Rationale: The correct answer is B because assessing lung sounds and extremities is crucial after significant weight gain in a patient with anorexia nervosa to monitor for potential complications like refeeding syndrome. Praise in choice A may reinforce unhealthy behaviors. Choice C suggesting an exercise program may be harmful. Choice D could lead to excessive weight gain.
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During a counseling session, the mother of one of the clients with an eating disorder states to the nurse, 'I feel like such a failure. How can I be sure my daughter has no more problems like this?' Which response is the most therapeutic?
- A. You are not responsible for your daughter's behavior.'
- B. Avoid giving advice and engaging in power struggles with your daughter.'
- C. It sounds like you are blaming yourself for your daughter's problems.'
- D. Try to ignore any problems your daughter has related to her eating disorder.'
Correct Answer: C
Rationale: Rationale:
C is the correct answer because it demonstrates empathy and reflects active listening. It acknowledges the mother's feelings without judgment and helps her explore her emotions. A: Blames the mother. B: Avoids addressing the mother's emotions. D: Dismisses the daughter's issues.
A child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty when the community mental health nurse visits to investigate the child's school absences. When the parents arrive home from work, the child's father behaves angrily. He orders his wife and son about. He finds fault with the son, asking him twice, 'Why are you such a stupid kid?' The wife tells the nurse she has difficulty disciplining the children and gets frustrated easily. The nurse desires to build some trust and continue to gather assessment data. The remark or question that would interfere with the nurse's goals is:
- A. Tell me what happens when the children misbehave.'
- B. When your baby cries, how do you get him to stop?'
- C. Caring for three young children must be difficult.'
- D. Do you or your husband ever beat the children?'
Correct Answer: D
Rationale: The correct answer is D. Asking about physical abuse can be perceived as accusatory, defensive, or judgmental, hindering trust-building and data collection. It may lead to denial or termination of communication. Choices A and B are relevant to understanding parenting skills, while C shows empathy. These questions align with the nurse's goal of assessing the family's dynamics without inciting defensiveness or shutting down communication.
A patient is admitted to the inpatient unit with a diagnosis of schizophrenia. The patient has had episodes of school absenteeism, withdrawal from friends, and bizarre behavior, including talking to his or her 'keeper.' The psychiatric-mental health nurse's most appropriate response is to:
- A. acknowledge that the patient's perceptions seem real to him or her, and refocus the patient's attention on a task or activity
- B. encourage the patient to express his or her thoughts, to determine the meaning they have for the patient
- C. ignore the patient's bizarre behavior, because it will diminish after he or she has been given the correct medication
- D. inform the patient that his or her perceptions of reality have become distorted because of the illness
Correct Answer: A
Rationale: Validating the patient's experience while redirecting to reality-based activity builds trust and reduces agitation without confrontation.
An elderly patient brings a bag of medications to the clinic. The nurse finds bottles of medications as well as assorted pills in no containers in the bag. What is the nurse's priority action?
- A. Dispose of all medications that are not in properly labeled bottles.
- B. Confer with a family member about the patient's management of medication.
- C. Engage the patient in education about safe storage and labeling of medication.
- D. Ask the patient to name the purpose and date of expiration of each medication not in a bottle.
Correct Answer: C
Rationale: The correct answer is C because engaging the patient in education about safe storage and labeling of medication is the priority action. This approach promotes patient understanding and empowerment in managing their medications safely. It addresses the immediate concern of the medications being improperly stored and unlabeled. Option A focuses solely on disposal without addressing the root cause. Option B involves a third party and may not address the patient's immediate needs. Option D is important but not as urgent as ensuring safe storage and labeling. Ultimately, educating the patient promotes long-term safety and adherence to medication management.
The parent of a seriously mentally ill adult asks the nurse, 'Why are you making a referral to a vocational rehabilitation program? My child wont ever be able to hold a job.' Which is the nurses best reply?
- A. We make this referral to continue eligibility for federal funding.'
- B. Are you concerned that were trying to make your child too independent?'
- C. If you think the program would be detrimental, we can postpone it for a time.'
- D. Most patients are capable of employment at some level, competitive or supported.'
Correct Answer: D
Rationale: Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.