Nokea
A priority measure to teach a client who purges is:
- A. that purging endangers one's health.
- B. that individuals who are overweight can be well-adjusted.
- C. to seek out a trusted person when feeling the need to purge.
- D. to use laxatives rather than vomiting as a way to eliminate food.
Correct Answer: C
Rationale: Rationale: Choice C is correct because seeking out a trusted person when feeling the need to purge can help the client establish a supportive and healthy coping mechanism. It encourages open communication, emotional support, and accountability. This approach addresses the underlying issues contributing to the purging behavior, fostering long-term positive change. Choices A, B, and D are incorrect as they do not directly address the need for seeking support and establishing healthier coping strategies.
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A depressed patient who is taking a tricyclic antidepressant tells the nurse, "I don't think I can keep taking these pills. They make me very dizzy, especially when I stand up." The best nursing response is:
- A. That is annoying, but it is something most patients are able to learn to live with as time goes on. You'll get used to the medicine's side effects.
- B. The medicine can slow the body's adjustment of blood pressure when changing position; drinking more fluids and changing position slowly can help.
- C. Compared to the problems caused by the depression, it seems like a relatively small annoyance to have to put up with.
- D. All medicines have side effects, and this one is relatively mild. It could be that your depression is causing you to think negatively about the medicine.
Correct Answer: B
Rationale: The correct answer is B because tricyclic antidepressants can cause orthostatic hypotension leading to dizziness upon standing. Advising the patient to drink more fluids and change positions slowly can help alleviate this symptom. Choice A minimizes the patient's concern, which is not therapeutic. Choice C diminishes the patient's experience and feelings. Choice D dismisses the patient's symptoms and attributes them solely to the patient's negative thinking, which is not appropriate.
Which of the following is a common emotional response for patients with anorexia nervosa?
- A. Fear of gaining weight and loss of control over eating.
- B. Lack of concern about food intake and weight.
- C. Excessive joy and pride in achieving weight loss.
- D. Denial of the need for treatment and weight restoration.
Correct Answer: A
Rationale: The correct answer is A because fear of gaining weight and loss of control over eating are core features of anorexia nervosa. Patients with anorexia often have an intense fear of gaining weight, leading to restrictive eating behaviors. This fear is accompanied by a sense of loss of control over their eating habits.
Choice B is incorrect because lack of concern about food intake and weight is not a common emotional response in anorexia nervosa. Choice C is incorrect as excessive joy and pride in achieving weight loss are more characteristic of other eating disorders like bulimia nervosa or orthorexia. Choice D is incorrect because denial of the need for treatment and weight restoration may be present in some cases but is not a common emotional response in anorexia nervosa.
A client who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother describes her as shy and having few friends. Which would be an appropriate nursing diagnosis for this client?
- A. Anxiety related to a new environment as evidenced by isolation and not talking with peers
- B. Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers
- C. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others
- D. Disturbed thought processes related to a new environment as evidenced by isolation and minimal interactions with others
Correct Answer: B
Rationale: The correct answer is B: Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers. This is the most appropriate nursing diagnosis because schizoid personality disorder is characterized by a pattern of social detachment and limited emotional expression. The client's behavior of isolating herself and not engaging with peers aligns with impaired social interaction.
Choice A (Anxiety) is incorrect because the client's behavior is more indicative of social detachment rather than anxiety. Choice C (Ineffective coping) is incorrect as there is no evidence to suggest the client is using maladaptive coping strategies. Choice D (Disturbed thought processes) is incorrect as the client's presentation does not indicate any disturbances in thought processes, but rather a lack of social engagement.
An infant develops jaundice 6 hours after birth. Which one of the following is the most likely diagnosis?
- A. Haemolytic disease of the newborn.
- B. Umbilical sepsis.
- C. Physiological jaundice.
- D. Atresia of the bile ducts.
Correct Answer: A
Rationale: Jaundice within 24 hours of birth is pathological, often due to haemolytic disease of the newborn (A), such as Rh incompatibility causing rapid red cell breakdown. Physiological jaundice (C) typically appears after 24 hours, while umbilical sepsis (B), bile duct atresia (D), and neonatal hepatitis (E) are less likely to cause such early onset.
The average age for onset of anorexia nervosa is:
- A. 13 years old.
- B. 17 years old.
- C. 33 years old.
- D. 40 years old.
Correct Answer: B
Rationale: The correct answer is B (17 years old) because anorexia nervosa typically manifests during adolescence, around ages 15-19. This age range coincides with the developmental stage where body image concerns and societal pressures are heightened. Choice A (13 years old) is too young for the typical onset. Choices C (33 years old) and D (40 years old) are too late for onset, as anorexia nervosa usually begins earlier in life.