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A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:
- A. Gain 1 to 2 pounds.
- B. Exercise 1 hour daily.
- C. Take a laxative every 3 days.
- D. Weigh self accurately using balanced scales.
Correct Answer: A
Rationale: The correct answer is A: Gain 1 to 2 pounds. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). In anorexia nervosa, gaining weight is crucial for recovery. Weight gain indicates improved nutritional status and overall health. Option B is incorrect as excessive exercise can exacerbate the patient's condition. Option C is incorrect as laxative use is not a recommended treatment for anorexia nervosa. Option D is incorrect as self-weighing may lead to obsessive behavior in patients with eating disorders.
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A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
- A. Coma
- B. Seizures
- C. Hypotonia
- D. Respiratory depression
Correct Answer: D
Rationale: The correct answer is D: Respiratory depression. Flunitrazepam is a sedative-hypnotic drug that can cause central nervous system depression, leading to respiratory depression, which is life-threatening. Monitoring respiratory status is crucial to prevent respiratory failure.
A: Coma may occur but is a consequence of severe respiratory depression, hence monitoring respiratory status is more critical.
B: Seizures are not a common side effect of flunitrazepam and do not pose immediate life-threatening risks compared to respiratory depression.
C: Hypotonia (muscle weakness) is a potential side effect but does not require immediate intervention like respiratory depression.
In summary, monitoring for respiratory depression is the priority as it can lead to respiratory failure and death, while the other choices are not as immediately life-threatening.
State four (4) negative symptoms of schizophrenia
- A. Apathy
- B. Social withdrawal
- C. Blunted affect
- D. Poverty of speech
Correct Answer: A
Rationale: Negative symptoms involve diminished function, such as lack of emotion, isolation, flat affect, and reduced verbal output.
Which of the following behaviors is characteristic of anorexia nervosa?
- A. Binge eating followed by purging.
- B. Self-induced vomiting after meals.
- C. Restricting food intake and an intense fear of gaining weight.
- D. Eating large quantities of food and then exercising excessively.
Correct Answer: C
Rationale: The correct answer is C because anorexia nervosa is characterized by restricting food intake and having an intense fear of gaining weight. This behavior leads to severe weight loss and malnutrition. Choice A is typically associated with bulimia nervosa, where binge eating is followed by purging. Choice B also aligns with bulimia, as self-induced vomiting is a common purging behavior. Choice D describes behaviors more typical of binge eating disorder, where individuals consume large quantities of food followed by excessive exercise. In anorexia nervosa, the primary focus is on severe food restriction and the fear of weight gain, leading to significantly low body weight.
A patient's medical record documents sexual masochism. This patient derives sexual pleasure
- A. from inanimate objects.
- B. by inflicting pain on a partner.
- C. when sexually humiliated by a partner.
- D. from touching a nonconsenting person.
Correct Answer: C
Rationale: The correct answer is C because sexual masochism involves deriving sexual pleasure from being humiliated or degraded by a partner. This behavior is characterized by finding arousal in receiving physical or emotional pain or humiliation during sexual activities. Choices A, B, and D are incorrect because they do not align with the specific behavior associated with sexual masochism. Choice A refers to objectophilia, choice B describes sadism, and choice D pertains to non-consensual sexual behavior, none of which are indicative of sexual masochism.
Which of the following are considered red flags for a communication disorder?
- A. Speech onset at 24 months, lack of pointing to indicate needs, and poor eye contact
- B. Short attention, odd intonation of speech, and poor pretend play
- C. Lack of pointing to show interests or needs, poor eye contact, and reduced joint attention
- D. Weak vocabulary, reduced joint attention, and poor interaction with peers
Correct Answer: C
Rationale: Red flags for communication disorders include lack of pointing to show interests/needs, poor eye contact, and reduced joint attention, as these indicate deficits in social communication, per developmental guidelines.