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A client is being assessed by a nurse after being diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?
- A. Weight gain and increased appetite
- B. Lanugo on the face and back
- C. Increased body temperature and tachycardia
- D. Hyperactivity and distractibility
Correct Answer: B
Rationale: In anorexia nervosa, individuals often develop lanugo, fine soft hair, on the face and back. This is a physiological response to the body's attempt to conserve heat due to a lack of subcutaneous fat. It is a common physical finding in clients with anorexia nervosa and can be a sign of severe malnutrition. Choices A, C, and D are incorrect because weight gain and increased appetite, increased body temperature and tachycardia, and hyperactivity and distractibility are not typically associated with anorexia nervosa. In fact, weight loss, decreased appetite, hypothermia, and bradycardia are more commonly seen in individuals with anorexia nervosa.
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What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?
- A. Allow the client to continue the ritualistic behavior initially
- B. Immediately stop the client from performing the ritual
- C. Encourage the client to perform the ritual more quickly
- D. Provide a distraction to interrupt the ritual
Correct Answer: A
Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.
A distraught, single, first-time mother cries and asks a nurse, 'How can I go to work if I can't afford childcare?' What is the nurse's initial action in assisting the client with the problem-solving process?
- A. Determine the risks and benefits of each alternative.
- B. Formulate goals for resolving the problem.
- C. Evaluate the outcome of the implemented solution.
- D. Assess the facts of the situation.
Correct Answer: D
Rationale: In this scenario, the nurse's first step should be to assess the facts of the situation. By gathering accurate information about the client's circumstances related to childcare and work, the nurse can better understand the client's needs and concerns, which is essential before proceeding with any problem-solving process. Choice A is incorrect because assessing risks and benefits comes later in the problem-solving process. Choice B is incorrect as formulating goals should follow a thorough assessment. Choice C is incorrect since evaluating outcomes happens after implementing a solution, which is premature at this stage.
A physically and emotionally healthy client has just been fired. During a routine office visit, he states to a nurse: 'Perhaps this was the best thing to happen. Maybe I'll look into pursuing an art degree.' How should the nurse characterize the client's appraisal of the job loss stressor?
- A. Irrelevant
- B. Harm/loss
- C. Threatening
- D. Challenging
Correct Answer: D
Rationale: The client's statement indicates that he views the job loss as an opportunity for growth and a new direction in life rather than a threat or harm/loss. He sees it as a challenge and is considering it positively, demonstrating resilience and adaptability in the face of adversity. Choice A, 'Irrelevant,' is incorrect as the client's response shows relevance and a positive outlook. Choice B, 'Harm/loss,' is incorrect as the client does not express a sense of harm or loss but rather opportunity. Choice C, 'Threatening,' is incorrect as the client's response does not convey fear or threat but rather a positive reframe of the situation.
When assessing a client diagnosed with major depressive disorder who states, 'I feel like I can't go on,' which of the following actions should the nurse take first?
- A. Administer a prescribed antidepressant medication.
- B. Ask the client if they have a plan to commit suicide.
- C. Encourage the client to attend a support group.
- D. Contact the client's family to provide support.
Correct Answer: B
Rationale: The priority action for the nurse is to assess the client's risk for suicide. By asking if the client has a plan to commit suicide, the nurse can determine the immediate safety of the client and take appropriate interventions to prevent harm. Administering antidepressant medication is not the first action to take in this situation as assessing the client's safety is the priority. Encouraging the client to attend a support group or contacting the client's family, although beneficial, are not immediate actions to ensure the client's safety in a crisis situation.
A client with borderline personality disorder is receiving care. Which of the following interventions should be included in the plan of care?
- A. Set clear and consistent boundaries
- B. Encourage independence
- C. Avoid discussing the client's feelings
- D. Use a firm, authoritative approach
Correct Answer: B
Rationale: When caring for a client with borderline personality disorder, it is essential to encourage independence rather than dependency. This helps promote autonomy and self-reliance, which are important aspects of treatment. Setting clear and consistent boundaries is also crucial, as it provides structure and predictability. Avoiding discussing the client's feelings is not recommended, as addressing emotions and promoting emotional awareness is a key part of therapy. Using a firm, authoritative approach may not be the most effective strategy as it can lead to power struggles and conflicts in individuals with borderline personality disorder.