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A rape victim tells the emergency room nurse, 'I feel so dirty. Help me take a shower before anything else.' The nurse should:
- A. Arrange for the patient to shower.
- B. Explain that bathing would destroy evidence.
- C. Suggest the patient wait until after the examination.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Explain that bathing would destroy evidence. This is the best choice because preserving evidence is crucial in cases of sexual assault. Bathing could wash away vital evidence needed for investigation and prosecution. It is important to prioritize the victim's physical and emotional well-being, but preserving evidence for forensic examination takes precedence. Choices A, C, and D are incorrect because arranging for the patient to shower, suggesting waiting, or choosing none of the above would risk compromising the evidence needed for justice.
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What is the most important goal for a nurse when providing care for a patient with bulimia nervosa?
- A. To promote weight loss through strict dietary control.
- B. To help the patient eliminate purging behaviors and develop healthy eating habits.
- C. To encourage excessive exercise to balance caloric intake.
- D. To focus solely on addressing body image issues.
Correct Answer: B
Rationale: The correct answer is B: To help the patient eliminate purging behaviors and develop healthy eating habits. This goal is important because it addresses the core issues of bulimia nervosa, which are unhealthy purging behaviors and distorted eating patterns. By helping the patient stop purging and establish healthy eating habits, the nurse can promote long-term recovery and overall well-being.
Choice A is incorrect because promoting weight loss through strict dietary control can exacerbate the patient's unhealthy relationship with food and body image. Choice C is incorrect as encouraging excessive exercise can contribute to a cycle of compulsive behaviors and worsen the patient's physical and mental health. Choice D is incorrect because focusing solely on body image issues neglects the underlying psychological factors contributing to bulimia nervosa.
The physician prescribes haloperidol (Haldol), a first-generation antipsychotic drug, for a patient with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should most be monitored to evaluate the expected improvement from this medication?
- A. Talking to himself, belief that others will harm him
- B. Flat affect, avoidance of social activities, poor hygiene
- C. Loss of interest in recreational activities, alogia
- D. Impaired eye contact, needs help to complete tasks
Correct Answer: A
Rationale: The correct answer is A because the symptoms of delusions and hallucinations are key indicators of improvement in schizophrenia with antipsychotic treatment. These symptoms directly relate to the patient's perception of reality and are core features of the disorder. Monitoring these symptoms provides objective evidence of the medication's effectiveness in addressing the patient's psychotic symptoms.
Choices B, C, and D are incorrect because they mainly indicate negative symptoms of schizophrenia, such as flat affect, social withdrawal, and cognitive deficits. While monitoring these symptoms is important for assessing overall functioning and quality of life, they are not the primary target of improvement with antipsychotic medications. Symptoms like delusions and hallucinations are considered primary targets for evaluating the efficacy of antipsychotic treatment in schizophrenia.
In refeeding syndrome that develops during nutritional rehabilitation of a patient with eating disorder, what is the most important biochemical change?
- A. Hypomagnesemia
- B. Hypophosphatemia
- C. Hypokalaemia
- D. Hypoglycaemia
Correct Answer: B
Rationale: Hypophosphatemia is the most critical biochemical change in refeeding syndrome, as it can lead to severe complications like cardiac arrest.
A nurse is providing care for a patient diagnosed with bulimia nervosa. What is a priority nursing intervention?
- A. Encourage regular exercise to promote weight loss.
- B. Provide a calm, structured environment with consistent mealtimes.
- C. Focus on weight loss as the most important goal.
- D. Offer the patient a high-protein diet to restore health.
Correct Answer: B
Rationale: The correct answer is B: Provide a calm, structured environment with consistent mealtimes. This is the priority intervention because individuals with bulimia nervosa benefit from a stable and supportive environment to establish regular eating patterns and reduce anxiety around mealtimes. This intervention helps promote a sense of safety and predictability, which are crucial for managing the eating disorder. Encouraging regular exercise (Choice A) may exacerbate compulsive behaviors related to bulimia. Weight loss (Choice C) should not be the focus as it can worsen the patient's condition. Offering a high-protein diet (Choice D) may not address the underlying psychological issues associated with bulimia.
The Omnibus Budget Reconciliation Act (OBRA) provides standards of care for which of the following:
- A. Very young
- B. Older adults
- C. Those who have certain intellectual communication difficulties
- D. Those without medical insurance
Correct Answer: B
Rationale: OBRA provides regulations for proper assessment of the elderly (B); for this reason, registered nurses have to provide the initial physical assessment.