Nokea
A patient with anorexia nervosa is at risk for refeeding syndrome. The nurse should be most concerned with:
- A. Hyperglycemia.
- B. Electrolyte imbalances, particularly hypophosphatemia.
- C. Increased hunger and overeating.
- D. Rapid weight gain and hypertension.
Correct Answer: B
Rationale: The correct answer is B: Electrolyte imbalances, particularly hypophosphatemia. Refeeding syndrome occurs when a malnourished individual receives nutrition too quickly, leading to shifts in electrolytes like phosphate, potassium, and magnesium. Hypophosphatemia is a key concern due to its potential to cause cardiac and respiratory failure. Hyperglycemia (A) may occur but is not the primary concern. Increased hunger and overeating (C) are common symptoms of anorexia nervosa but not directly related to refeeding syndrome. Rapid weight gain and hypertension (D) are potential consequences of refeeding but are not the immediate concern compared to electrolyte imbalances.
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Bacteria, such as E. Coli, in our water can come from
- A. Factory run-off
- B. Car exhaust
- C. Human and animal feces
- D. Littering
Correct Answer: C
Rationale: E. Coli primarily originates from fecal contamination by humans or animals, making it a common water pollutant.
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
- A. agranulocytosis"¦check the patient's complete blood count for changes
- B. tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale
- C. Tourette's syndrome"¦consult the patient's physician about a neuro evaluation
- D. anticholinergic effects"¦consult the physician about possible medication changes
Correct Answer: B
Rationale: The correct answer is B: tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale.
1. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications like fluphenazine.
2. The symptoms described - grimacing, lip smacking, twisting neck and shoulders - are characteristic of tardive dyskinesia.
3. Administering the Abnormal Involuntary Movement Scale is the appropriate assessment tool for diagnosing tardive dyskinesia.
4. Agranulocytosis (choice A) is a rare but serious side effect of some antipsychotic medications, not associated with the symptoms described.
5. Tourette's syndrome (choice C) typically presents with vocal and motor tics, not the specific symptoms mentioned.
6. Anticholinergic effects (choice D) can cause dry mouth, constipation, and blurred vision, but not the involuntary movements described.
A nurse planning a group to help batterers learn more effective ways to cope would teach participants that the key component in wife battering is:
- A. The need for the batterer to control
- B. Alcohol abuse by the batterer
- C. History of psychotic behavior
- D. Failure of the woman to assert herself
Correct Answer: A
Rationale: The correct answer is A: The need for the batterer to control. This is the key component in wife battering, as it is rooted in the batterer's desire to establish power and dominance over their partner. Teaching batterers more effective ways to cope involves addressing this underlying need for control.
Explanation of other choices:
B: Alcohol abuse by the batterer - While alcohol abuse may exacerbate violent behavior, it is not the primary cause of wife battering.
C: History of psychotic behavior - Psychotic behavior may contribute to violence, but it is not the key component in wife battering.
D: Failure of the woman to assert herself - Blaming the victim is not appropriate; the responsibility lies with the batterer's need for control.
A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who:
- A. consumes 1 glass of wine nightly with dinner
- B. began drinking alcohol daily after retirement and says, 'A few drinks keep my mind off my arthritis.'
- C. drank socially throughout adult life and continues this pattern, saying 'Ive earned the right to do as I please.'
- D. abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA)
Correct Answer: B
Rationale: Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.
A group of teenagers are discussing their individual problems associated with having an eating disorder. Which findings would the nurse attribute to purging?
- A. Excessive facial hair
- B. Elevated blood pressure
- C. Polyuria
- D. Dental enamel erosion
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Polyuria):
1. Purging involves self-induced vomiting or misuse of laxatives/diuretics.
2. Vomiting can lead to electrolyte imbalances, causing increased urine production (polyuria).
3. Polyuria is a common sign of purging behaviors due to electrolyte disturbances.
Summary of Incorrect Choices:
A: Excessive facial hair - Not directly related to purging behavior.
B: Elevated blood pressure - Could be related to stress or other factors, not specific to purging.
D: Dental enamel erosion - More likely associated with frequent vomiting (purging) rather than polyuria.