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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 assesses that which of the following individuals is most likely to engage in eating behaviors characteristic of bulimia?
- A. A person who weighs 225 pounds and is 5 feet 4 inches tall.
- B. A person who is 5 pounds overweight and cannot stick to a diet.
- C. A person who lost up to 40 pounds but gained it back within 1 year.
- D. None of the above.
Correct Answer: A
Rationale: Step 1: Individuals with bulimia often engage in episodes of binge eating followed by purging behaviors.
Step 2: Choice A, a person who is significantly overweight, is more likely to engage in binge eating behavior.
Step 3: Being overweight can be a risk factor for bulimia due to body image concerns.
Step 4: Choices B and C do not provide as strong indicators for bulimia as choice A.
Summary: Choice A is correct as being significantly overweight is a common characteristic of individuals with bulimia. Choices B and C lack the same level of risk factors for engaging in eating behaviors characteristic of bulimia.
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
- A. Lithium (Lithobid).
- B. Buspirone (BuSpar).
- C. Risperidone (Risperdal).
- D. Fluphenazine (Prolixin)
Correct Answer: D
Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.
After being raped, a woman was told by her aunt, 'I'm not surprised that happened to you. You were asking for it.' A few days later, a friend told her, 'Well after all, he took you to dinner. He expected something in return.' The victim states, 'I can't believe that people can think that way.' The rape crisis nurse correctly hypothesizes that the client is:
- A. Experiencing cognitive dissonance.
- B. In denial about the rape.
- C. Seeking validation from others.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Experiencing cognitive dissonance. Cognitive dissonance refers to the mental discomfort or conflict that occurs when a person's beliefs or attitudes are inconsistent with their actions or experiences. In this scenario, the woman is facing conflicting beliefs - she knows she did not ask for or deserve to be raped, yet the comments from her aunt and friend suggest otherwise. This leads to the woman feeling disbelief and distress.
Summary:
B: In denial about the rape - This choice does not address the conflicting beliefs the woman is experiencing.
C: Seeking validation from others - While seeking validation may be a natural response, it does not capture the essence of cognitive dissonance in this context.
An adult patient tells the case manager, 'I dont have bipolar disorder anymore, so I dont need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now Im bored and dont have any friends.' Where should the nurse refer the patient? Select one tha does not apply.
- A. Psychoeducational classes
- B. Vocational rehabilitation
- C. Social skills training
- D. A homeless shelter
Correct Answer: D
Rationale: The patient does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with serious mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The patient presently has a home and does not require a homeless shelter.
Which of the following is an effective communication technique that should be included in the teaching plan for the family members of a woman in whom Alzheimer's disease has been diagnosed recently?
- A. Use simple, familiar words, along with short and simple sentences.
- B. If the client tends to pace a lot, be sure to encourage her to sit during interactions.
- C. If she doesn't understand the communication, change key words.
- D. Use hand gestures when speaking to try to explain what is being said.
Correct Answer: A
Rationale: The correct answer is A: Use simple, familiar words, along with short and simple sentences. This is an effective communication technique for individuals with Alzheimer's disease as it helps in enhancing understanding and reduces confusion. Complex language or sentences may be difficult for the patient to comprehend.
Choice B is incorrect because encouraging the client to sit during interactions does not directly relate to effective communication techniques. Choice C is incorrect as changing key words can lead to further confusion and may not aid in understanding. Choice D is incorrect because using hand gestures may not always effectively convey the message and can potentially cause more confusion for individuals with Alzheimer's disease.