Nokea
A patient with borderline personality disorder has cut her wrists. The physician orders daily dressing changes for the lacerations. The nurse performing this care should:
- A. encourage the patient to vent anger and aggression.
- B. provide care in a matter-of-fact manner
- C. be kindly, sympathetic, and concerned.
- D. offer to listen to the patient's feelings about cutting.
Correct Answer: B
Rationale: The correct answer is B: provide care in a matter-of-fact manner. This approach is important in treating patients with borderline personality disorder as it helps maintain boundaries and consistency, which are crucial for managing their condition. By being matter-of-fact, the nurse can prevent potential manipulation or reinforcement of maladaptive behaviors. Encouraging the patient to vent anger (choice A) may escalate the situation. Being overly sympathetic (choice C) can blur professional boundaries. Offering to listen to feelings (choice D) may reinforce the behavior and not address the underlying issues effectively.
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Which of these nursing communications best reflects the nurse's use of an empowerment model with an individual who has been abused?
- A. Let me share with you my knowledge of what happens psychologically to individuals who have been abused.'
- B. I know you feel that your partner will change, but the current research does not validate your thinking.'
- C. It's up to you to end the violence. You are the only one who can set limits on how your partner is allowed to treat you.'
- D. Let's consider what you believe your options are in terms of your relationship with your partner in light of the behavior toward you.'
Correct Answer: D
Rationale: The correct answer, D, reflects the nurse's use of an empowerment model because it focuses on exploring the individual's beliefs and options, empowering them to make informed decisions. The nurse is not imposing their own knowledge or opinions but instead facilitating the individual's self-reflection and decision-making process. This approach respects the individual's autonomy and promotes empowerment by helping them identify and evaluate their own choices.
Choice A focuses on the nurse sharing knowledge, which may come across as patronizing and disempowering. Choice B dismisses the individual's feelings and relies on research rather than empowering the individual to make their own decisions. Choice C places the responsibility solely on the individual to end the violence, which may feel overwhelming and lacking in support or guidance.
The mother of a client newly diagnosed with schizophrenia is a nurse. She unhappily tells the nurse on the unit, 'I've tried to be a good mother, but my daughter still developed schizophrenia. When I was in school, we were taught that it was the mother's fault if a child became schizophrenic. I wish I knew what I did wrong.' The response that would help the mother evaluate models explaining schizophrenia would be:
- A. I can see how you would be upset over this turn of events.'
- B. New findings suggest this disorder is biologic in nature.'
- C. Don't be so hard on yourself; your daughter needs you to be strong.'
- D. It's difficult to see that double-bind communication produces stress for the child at the time it's occurring.'
Correct Answer: B
Rationale: Correct answer: B
Rationale:
1. This response acknowledges the mother's distress but shifts the focus to new findings suggesting schizophrenia is biologic in nature.
2. It provides the mother with updated information that contradicts the outdated belief that mothers are to blame for schizophrenia.
3. By highlighting the biological basis of the disorder, it helps the mother understand that it is not her fault.
4. This response encourages the mother to consider scientific evidence rather than blaming herself, promoting a more accurate understanding of the condition.
Summary:
- Choice A validates the mother's feelings but doesn't offer factual information to challenge her belief.
- Choice C aims to provide emotional support but doesn't address the mother's need for accurate information.
- Choice D introduces the concept of double-bind communication, which is not directly relevant to helping the mother understand the biological nature of schizophrenia.
What is the priority assessment for a patient with bulimia nervosa who is experiencing frequent purging behaviors?
- A. Monitor for signs of electrolyte imbalances and dehydration.
- B. Assess for any weight gain and increase exercise habits.
- C. Encourage the patient to express feelings about food and body image.
- D. Monitor for compulsive eating behaviors and binge episodes.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of electrolyte imbalances and dehydration. This is the priority assessment for a patient with bulimia nervosa who is experiencing frequent purging behaviors because purging can lead to electrolyte imbalances and dehydration, which can result in serious health complications such as cardiac arrhythmias and renal issues. Monitoring electrolyte levels and hydration status is crucial for the patient's safety and well-being.
Summary:
- Choice B is incorrect because focusing on weight gain and exercise habits is not the priority when dealing with the immediate health risks of electrolyte imbalances and dehydration.
- Choice C is incorrect as expressing feelings about food and body image is important for therapy but not the priority in this acute situation.
- Choice D is incorrect as monitoring for compulsive eating behaviors and binge episodes is more relevant for patients with binge eating disorder rather than bulimia nervosa with frequent purging behaviors.
The client is hostile, angry, and suspicious. He thinks that the staff is trying to poison him. He is classified as:
- A. Paranoid
- B. Catatonic
- C. Disorganized
- D. Undifferentiated
Correct Answer: A
Rationale: The correct answer is A: Paranoid. This client's behavior aligns with paranoid schizophrenia symptoms, characterized by hostility, anger, suspicion, and delusions of persecution like being poisoned. Catatonic schizophrenia (B) involves motor disturbances, disorganized schizophrenia (C) features disorganized speech and behavior, and undifferentiated schizophrenia (D) includes a mix of symptoms without fitting a specific subtype. Paranoid schizophrenia best fits the client's presentation based on the described symptoms.
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?
- A. Eating disorder not otherwise specified
- B. Anorexia nervosa
- C. Bulimia nervosa
- D. Binge eating
Correct Answer: B
Rationale: The correct diagnosis is B: Anorexia nervosa. This patient exhibits key symptoms such as restrictive eating leading to significant weight loss, wearing layers of clothing to hide body shape, and amenorrhea. These symptoms align with the diagnostic criteria for anorexia nervosa. The other choices are incorrect because they do not fully capture the combination of symptoms present in this case. Choice A (Eating disorder not otherwise specified) is too broad and does not specify the severity of the symptoms. Choice C (Bulimia nervosa) typically involves binge eating followed by compensatory behaviors, which is not indicated in this case. Choice D (Binge eating) focuses solely on overeating without the restrictive eating and weight loss seen in anorexia nervosa.