Nokea
A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Initiate caloric and nutritional therapy.
- B. Implement behavioral modification therapy.
- C. Evaluate the client for low self-esteem.
- D. Record daily weights and graph trends.
Correct Answer: A
Rationale: The client presents with evidence of anorexia nervosa resulting from self-starvation, which is a life-threatening condition. Providing nutrition and calories is the priority intervention so that the risk of electrolyte imbalance and severe dehydration can be reduced. Behavioral modification therapy (Choice B) may be beneficial in the long term but is not the priority in this acute situation. Evaluating for low self-esteem (Choice C) may be part of the nursing assessment but does not address the immediate life-threatening issues. Recording daily weights and graphing trends (Choice D) is important for monitoring progress but does not address the critical need for nutritional therapy in this case.
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What intervention is likely to be most effective in returning a middle-aged adult with major depressive disorder who suffers from psychomotor retardation, hypersomnia, and amotivation to a normal level of functioning?
- A. Encourage the client to exercise.
- B. Suggest that the client develop a list of pleasurable activities.
- C. Provide education on methods to enhance sleep.
- D. Teach the client to develop a plan for daily structured activities.
Correct Answer: D
Rationale: The most effective intervention for a middle-aged adult with major depressive disorder experiencing psychomotor retardation, hypersomnia, and amotivation is to teach the client to develop a plan for daily structured activities. This intervention helps combat the symptoms by providing a routine and purpose to the client's day, addressing the issues of psychomotor retardation and amotivation. Structured activities can help establish a sense of normalcy, improve motivation, and regulate sleep patterns. Encouraging exercise (Choice A) can be beneficial but may be challenging for a client experiencing psychomotor retardation. Developing a list of pleasurable activities (Choice B) may not address the need for structure and routine in the client's daily life. Providing education on sleep enhancement methods (Choice C) is important but may not be sufficient to address the overall functional impairment in this case.
Gilbert, age 19, is described by his parents as a 'moody child' with an onset of odd behavior around age 14, which caused him to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:
- A. Favorable with medication
- B. In the relapse stage
- C. Improvable with psychosocial interventions
- D. To have a less positive outcome
Correct Answer: D
Rationale: In cases of early and slow onset of schizophrenia, the prognosis is generally less positive. This means that the outlook for individuals like Gilbert, who showed signs of schizophrenia at a young age, is often poorer. Option A is incorrect because while medication can help manage symptoms, the overall prognosis is still less favorable. Option B is incorrect since relapse stage typically refers to a period of worsening symptoms after initial improvement. Option C is incorrect because while psychosocial interventions can be beneficial, the underlying early and slow onset of schizophrenia indicates a less positive outcome.
The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?
- A. Lithium (Lithotabs).
- B. Benztropine (Cogentin).
- C. Alprazolam (Xanax).
- D. Magnesium (Milk of Magnesia).
Correct Answer: B
Rationale: The correct answer is Benztropine (Cogentin). Benztropine is commonly prescribed to manage side effects of antipsychotic medications. Therefore, if the antipsychotic medication is discontinued, there would be no need for Benztropine. Lithium is a mood stabilizer used in bipolar disorder, not directly related to antipsychotic use. Alprazolam is an anxiolytic, and Magnesium (Milk of Magnesia) is a laxative, neither of which is typically associated with antipsychotic medication use.
An adolescent with anorexia nervosa is undergoing nutritional therapy. Which finding best indicates that the client is making progress in treatment?
- A. Client gains 2 pounds in a week.
- B. Client describes a positive body image.
- C. Client engages in recreational activities.
- D. Client begins to talk about future goals.
Correct Answer: A
Rationale: The correct answer is A. Weight gain is a crucial indicator of progress in the treatment of anorexia nervosa. In individuals with anorexia, restoring and maintaining a healthy weight is a primary goal to address the underlying nutritional deficiencies and health complications associated with the disorder. While choices B, C, and D are positive developments in the client's overall well-being and recovery journey, they are not as directly linked to the core issue of nutritional rehabilitation in anorexia nervosa. Describing a positive body image, engaging in recreational activities, and talking about future goals are important aspects of psychological and emotional recovery, but weight gain is a more immediate and objective measure of progress in treating anorexia nervosa.
When changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen, which approach should the RN use?
- A. Provide detailed and thorough explanations while cleansing the wound.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask why the client cut their own abdomen in a non-threatening manner.
- D. Request assistance from another staff member for the dressing change.
Correct Answer: B
Rationale: The correct approach for the RN when changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen is to perform the dressing change in a non-judgmental manner. This approach helps maintain therapeutic rapport and respect for the client's situation. Choice A is incorrect because providing detailed and thorough explanations may not be as important as maintaining a non-judgmental attitude. Choice C is incorrect because asking why the client cut their own abdomen may come across as accusatory or threatening, which can be counterproductive in building trust. Choice D is incorrect because the RN should be equipped to handle the dressing change independently while ensuring a supportive and non-judgmental environment for the client.