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After assessing a patient with anorexia nervosa, a nurse writes the following nursing diagnosis: imbalanced nutrition, less than body requirements related to refusal to eat as evidenced by being 25% below body weight for height. The expected outcome should be listed as:
- A. Patient will identify cognitive distortions about food, weight, and body shape.'
- B. Patient will exhibit fewer signs of malnutrition within 2 weeks of hospitalization.'
- C. Patient will be able to describe both the physical and emotional complications of the eating disorder.'
- D. Patient will restore healthy eating patterns and normalize physiological parameters related to weight and nutrition.'
Correct Answer: D
Rationale: The correct answer is D because the expected outcome for a patient with imbalanced nutrition due to anorexia nervosa should focus on restoring healthy eating patterns and normalizing physiological parameters related to weight and nutrition. This outcome directly addresses the underlying issue of inadequate nutrition intake and helps the patient achieve a healthier state.
A: While identifying cognitive distortions is important for addressing the psychological aspects of anorexia nervosa, it does not directly address the patient's nutritional needs.
B: Exhibiting fewer signs of malnutrition is a vague outcome and does not specify how the patient will achieve this improvement.
C: Describing physical and emotional complications is informative but does not address the primary goal of improving nutrition intake and weight restoration.
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When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a 'zombie.' What other common side effects should the nurse determine if the patient experienced?
- A. Sweating, nausea, and weight gain
- B. Sedation, tremor, and muscle stiffness
- C. Headache, watery eyes, and runny nose
- D. Mild fever, sore throat, and skin rash
Correct Answer: B
Rationale: The correct answer is B: Sedation, tremor, and muscle stiffness. These side effects are commonly associated with conventional antipsychotic medications like chlorpromazine. Sedation is a common side effect that can make the patient feel drowsy or sluggish. Tremors are involuntary muscle movements that can affect the hands, arms, or legs. Muscle stiffness can cause rigidity and difficulty moving smoothly. These side effects are known to impact the quality of life and may contribute to the patient feeling like a 'zombie.'
Choices A, C, and D are incorrect because they do not align with the common side effects of conventional antipsychotic medications. Sweating, nausea, and weight gain (Choice A) are not typical side effects of chlorpromazine. Headache, watery eyes, and runny nose (Choice C) are more commonly associated with allergies or cold symptoms rather than antipsychotic medications. Mild fever, sore throat, and skin rash (Choice D)
A client with a borderline personality disorder tells the nurse, 'My doctor tells me there's something wrong with the hard wiring of my brain, and that's why I'm so impulsive and get so many mood swings. He said he's going to prescribe some medication.' Being aware of current practice guidelines, the nurse will prepare a teaching plan for:
- A. Lithium
- B. Fluoxetine
- C. Lorazepam
- D. Haloperidol
Correct Answer: B
Rationale: The correct answer is B: Fluoxetine. Borderline personality disorder (BPD) is primarily treated with psychotherapy, but in some cases, medication is used to manage symptoms like impulsivity and mood swings. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is commonly used to address mood instability and impulsivity in BPD. SSRIs help regulate serotonin levels in the brain, which can improve mood stability and decrease impulsive behaviors. Lithium (choice A) is used for bipolar disorder, not BPD. Lorazepam (choice C) is a benzodiazepine used for anxiety and not typically recommended for BPD. Haloperidol (choice D) is an antipsychotic used for conditions like schizophrenia and not typically indicated for BPD.
When coping with a patient's inappropriate expression of anger, a psychiatric-mental health nurse's initial action is to identify the:
- A. appropriate limit-setting techniques
- B. nurse's own response to the anger
- C. patient's specific defense mechanisms
- D. systems theory for effecting change
Correct Answer: B
Rationale: Understanding the nurse's own emotional response ensures objectivity and effective management of the patient's anger.
A 45-year-old married woman who works full time in a factory has recently been absent for 3-day periods on several occasions. Each time, she returned to work wearing dark glasses. Facial and body bruises were apparent. Her supervisor became suspicious that she was a victim of battering and referred her to the occupational health nurse. What should the nurse first focus on as she meets the patient?
- A. Notifying the police of the abuse
- B. Documenting the woman's injuries
- C. Establishing trust and building rapport
- D. Collecting evidence to prosecute the abuser
Correct Answer: C
Rationale: The correct answer is C: Establishing trust and building rapport. The nurse should first focus on building a trusting relationship with the patient to create a safe environment for her to disclose any abuse she may be experiencing. By establishing trust and rapport, the nurse can gain the patient's confidence and encourage her to open up about her situation. This approach is crucial in ensuring the patient feels supported and empowered to seek help.
Incorrect choices:
A: Notifying the police of the abuse - This may jeopardize the patient's safety and could worsen the situation if she is not ready to involve law enforcement.
B: Documenting the woman's injuries - While documenting injuries is important, it should not be the first step as it may further distress the patient without addressing the underlying issue.
D: Collecting evidence to prosecute the abuser - Prosecution should not be the initial focus; the priority should be on the patient's well-being and safety.
Which aspect of assessment has priority when a nurse interviews a rape victim?
- A. Coping mechanisms the patient is using
- B. The patient's previous sexual experiences
- C. Adequacy of the patient's interpersonal relationships
- D. Whether the patient has ever had a sexually transmitted disease
Correct Answer: A
Rationale: The correct answer is A: Coping mechanisms the patient is using. This aspect has priority because it helps the nurse assess the immediate emotional and psychological impact of the trauma on the victim. Understanding coping mechanisms can guide the nurse in providing appropriate support and interventions. Choice B is incorrect as past sexual experiences are not as pertinent during the immediate assessment of a rape victim. Choice C is incorrect as assessing interpersonal relationships may not be a priority during the initial interview. Choice D is incorrect as the presence of a sexually transmitted disease is not the primary concern when assessing a rape victim.