Age Specific Patient Care Quizlet

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A short-term goal for a patient with anorexia nervosa is 'Patient will select and eat a balanced diet.' The nurse writes which of the following nursing interventions into the care plan that will foster attainment of this goal?

  • A. Allow patient to weigh self every time a meal is completely eaten.
  • B. Assist the patient to fill out the dietary menus to ensure a balanced diet.
  • C. Encourage the patient to engage in only appropriate compensatory exercise.
  • D. Implement contracted consequences 50% of the time if a meal is not completed.
Correct Answer: B

Rationale: The correct answer is B: Assist the patient to fill out the dietary menus to ensure a balanced diet. This intervention is appropriate because it directly supports the goal of the patient selecting and eating a balanced diet. By assisting the patient in filling out dietary menus, the nurse can help the patient make informed choices about their food intake, ensuring they are consuming a variety of nutrients necessary for a balanced diet. This intervention promotes patient autonomy and education, empowering the patient to make healthier choices.

Choice A is incorrect because allowing the patient to weigh themselves every time a meal is eaten does not directly address the goal of selecting and eating a balanced diet.

Choice C is incorrect because encouraging compensatory exercise may lead to unhealthy behaviors and does not focus on achieving a balanced diet.

Choice D is incorrect because implementing contracted consequences for incomplete meals may create a negative environment and does not promote a positive approach to achieving a balanced diet.

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A client who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia developed tardive dyskinesia as evidenced by tongue thrusting and chewing motions. The physician discontinued the chlorpromazine and prescribed Seroquel (quetiapine). As a result of this change, the nurse should carefully monitor for:

  • A. Development of pseudoparkinsonism
  • B. Development of dystonic reactions
  • C. Improvement in tardive dyskinesia
  • D. Worsening of anticholinergic symptoms
Correct Answer: C

Rationale: The correct answer is C: Improvement in tardive dyskinesia. Tardive dyskinesia is a side effect of long-term antipsychotic use, like chlorpromazine. Quetiapine (Seroquel) is an atypical antipsychotic with a lower risk of causing tardive dyskinesia. By discontinuing chlorpromazine and switching to quetiapine, there is a higher likelihood of improvement or resolution of tardive dyskinesia symptoms. Options A and B are incorrect as they are related to other movement disorders caused by antipsychotics. Option D is incorrect as anticholinergic symptoms are not directly related to tardive dyskinesia improvement with the medication switch.

Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis?

  • A. Weight, muscle, and fat congruence with height, frame, age, and sex.
  • B. Calorie intake within required parameters of treatment plan.
  • C. Weight at established normal range for the patient.
  • D. None of the above.
Correct Answer: A

Rationale: The correct answer is A because disturbed body image in an eating disorder patient involves a discrepancy between their perceived body image and reality. Monitoring weight, muscle, and fat congruence with height, frame, age, and sex helps assess if the patient's perception aligns with their actual physical state. Choice B focuses solely on calorie intake, which does not directly address body image perception. Choice C only considers weight, neglecting the importance of muscle and fat distribution in body image perception. Choice D is incorrect as option A is the most relevant outcome indicator for disturbed body image in this scenario.

A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include?

  • A. Pain assessment techniques for older adults
  • B. Psychosocial stimulation for those who live alone
  • C. Preparation of psychiatric advance directives in the elderly
  • D. Ways to manage disinhibition in elderly persons with dementia
Correct Answer: A

Rationale: The correct answer is A: Pain assessment techniques for older adults. This is the highest priority as pain management is crucial in the care of the elderly to ensure their comfort and well-being. By assessing pain accurately, appropriate interventions can be implemented.

- Choice B (Psychosocial stimulation): While important, it is not as critical as addressing pain, which directly impacts the individual's physical comfort.
- Choice C (Psychiatric advance directives): Important for mental health planning but not as immediately essential as pain assessment in day-to-day care.
- Choice D (Managing disinhibition in dementia): Important but secondary to addressing pain, which has a more immediate impact on the individual's quality of life.

Prioritizing pain assessment ensures holistic care for elderly patients.

A client with undifferentiated schizophrenia is readmitted for an acute exacerbation of the disorder. The goal of hospitalization is symptom stabilization. The nurse has documented that, in addition to experiencing auditory hallucinations, the client seems uninterested in activities, has difficulty completing tasks, seems forgetful, and seems puzzled by information and directions given by staff. The nurse's plans for intervention will be effective if these behaviors are attributed to:

  • A. Social isolation
  • B. Deficient knowledge
  • C. Situational low self-esteem
  • D. Problems in cognitive functioning
Correct Answer: D

Rationale: The correct answer is D: Problems in cognitive functioning. In undifferentiated schizophrenia, cognitive deficits such as difficulty completing tasks, forgetfulness, and confusion are common symptoms. These behaviors are indicative of cognitive impairment rather than social isolation, deficient knowledge, or low self-esteem. Cognitive deficits in schizophrenia can affect memory, attention, and problem-solving abilities, leading to difficulties in daily functioning. Therefore, the nurse's interventions should focus on addressing these cognitive impairments to stabilize the client's symptoms.

An appropriate intervention for a client with an identified nursing diagnosis of Situational low self-esteem would be:

  • A. Encouraging verbalization of feelings in a safe environment
  • B. Attempting to determine triggers to hallucinations
  • C. Engaging client in activities designed to permit success
  • D. Providing large muscle activities to relieve stress
Correct Answer: C

Rationale: The correct answer is C: Engaging client in activities designed to permit success. This intervention is appropriate for addressing situational low self-esteem as it focuses on building the client's self-confidence through successful experiences. Engaging in activities that the client can excel at helps boost self-esteem and self-worth. By providing opportunities for success, the client can gain a sense of accomplishment, leading to improved self-esteem.

A: Encouraging verbalization of feelings in a safe environment may be beneficial for emotional expression, but it does not directly address building self-esteem through success.
B: Attempting to determine triggers to hallucinations is unrelated to addressing situational low self-esteem.
D: Providing large muscle activities to relieve stress may be helpful for stress management but does not directly target improving self-esteem through success.

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