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Care planning requires that a nurse recognize that the dynamic focus directing a patient with anorexia nervosa is:
- A. managing weight gain.
- B. controlling personal stressors.
- C. maintaining a sense of control.
- D. avoiding social interactions.
Correct Answer: C
Rationale: Step 1: Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted body image.
Step 2: Patients often use strict control over food intake as a way to cope with underlying emotional issues.
Step 3: Maintaining a sense of control is crucial in managing anorexia nervosa as it addresses the core psychological aspects driving the disorder.
Step 4: Managing weight gain (A) is not the primary focus as patients may resist gaining weight due to their fear.
Step 5: Controlling personal stressors (B) may be important but does not address the underlying issue of control related to food and body.
Step 6: Avoiding social interactions (D) does not address the core psychological need for control and can further isolate the patient.
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Which of the following are considered red flags for a communication disorder?
- A. Speech onset at 24 months, lack of pointing to indicate needs, and poor eye contact
- B. Short attention, odd intonation of speech, and poor pretend play
- C. Lack of pointing to show interests or needs, poor eye contact, and reduced joint attention
- D. Weak vocabulary, reduced joint attention, and poor interaction with peers
Correct Answer: C
Rationale: Red flags for communication disorders include lack of pointing to show interests/needs, poor eye contact, and reduced joint attention, as these indicate deficits in social communication, per developmental guidelines.
Which of the following interventions is most appropriate for a patient with bulimia nervosa?
- A. Encourage regular weight monitoring and restriction of food intake.
- B. Offer emotional support and focus on healthy coping mechanisms.
- C. Provide medications to induce vomiting after meals.
- D. Focus on achieving weight loss and reducing food intake.
Correct Answer: B
Rationale: The correct answer is B because offering emotional support and focusing on healthy coping mechanisms are crucial in treating bulimia nervosa. This approach addresses the psychological aspects of the disorder and helps the patient develop healthier behaviors. Regular weight monitoring and food restriction (choice A) can exacerbate the disorder by reinforcing a focus on weight and food. Medications to induce vomiting (choice C) can be harmful and do not address the underlying issues. Focusing on weight loss and reducing food intake (choice D) may worsen the patient's disordered eating behaviors and contribute to a cycle of restriction and bingeing.
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.
An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed. She admits to being very frightened. She is presently pacing and somewhat agitated in the examining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
- A. Interact with the client on an adult to child level.
- B. Place the client in a safe, nonstimulating environment.
- C. Ask client why she thinks someone would be trying to frighten her.
- D. Explain to the family that the client will be restrained for her own good.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a safe, nonstimulating environment. This is the most appropriate nursing intervention because the client is experiencing hallucinations and agitation, which could be due to the recent medication changes. Placing the client in a safe, calm environment can help reduce stimulation and provide a sense of security. This intervention addresses the client's immediate needs by ensuring her safety and promoting a sense of comfort.
Incorrect answers:
A: Interact with the client on an adult to child level - This is not appropriate as it does not address the client's current state of distress and could potentially worsen the situation.
C: Ask client why she thinks someone would be trying to frighten her - This is not the priority at this time, as the client is experiencing hallucinations and agitation that need to be managed first.
D: Explain to the family that the client will be restrained for her own good - Restraints should only be used as a last resort and should not be considered
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.