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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.
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Which is NOT a contributing factor to postpartum blues?
- A. Hormone shifts
- B. Lack of sleep
- C. Stress
- D. History of depression
Correct Answer: D
Rationale: History of depression (D) is a contributor to postpartum depression, not postpartum blues. Hormone shifts (A), lack of sleep (B), and stress (C) are common triggers for the transient sadness of postpartum blues.
Which factor least influences whether a country will have a higher life expectancy?
- A. The level of racial diversity
- B. Quality sanitation and sewage treatment facilities
- C. Access to food
- D. Access to medicine
Correct Answer: A
Rationale: Racial diversity has little direct impact on life expectancy compared to sanitation, food, and medical access, which are critical determinants.
Which documentation indicates that the treatment plan for a patient with acute mania was effective?
- A. Converses without interrupting; clothing matched; participates in activities.
- B. Irritable; suggestible; distractible; napped for 10 minutes in afternoon.
- C. Attention span 1 to 3 minutes; journals frequently about unit activities.
- D. Heavy makeup; seductive toward staff; pressured speech.
Correct Answer: A
Rationale: The correct answer is A because the behaviors described indicate that the patient is able to converse without interrupting, their clothing matches, and they participate in activities. These behaviors suggest improved impulse control, stable mood, and engagement in daily activities, indicating effectiveness of the treatment plan.
Choice B describes symptoms of mania such as irritability and distractibility, which would indicate ongoing symptoms rather than improvement. Choice C indicates a short attention span and excessive journaling, which are not indicative of effective treatment. Choice D describes behaviors suggestive of hypersexuality and pressured speech, which are not signs of improvement in acute mania.
A patient is admitted to the inpatient unit with a diagnosis of schizophrenia. The patient has had episodes of school absenteeism, withdrawal from friends, and bizarre behavior, including talking to his or her 'keeper.' The psychiatric-mental health nurse's most appropriate response is to:
- A. acknowledge that the patient's perceptions seem real to him or her, and refocus the patient's attention on a task or activity
- B. encourage the patient to express his or her thoughts, to determine the meaning they have for the patient
- C. ignore the patient's bizarre behavior, because it will diminish after he or she has been given the correct medication
- D. inform the patient that his or her perceptions of reality have become distorted because of the illness
Correct Answer: A
Rationale: Validating the patient's experience while redirecting to reality-based activity builds trust and reduces agitation without confrontation.
A client with antisocial personality disorder yells, 'Shut up about that, or I'll punch you in the nose!' and shakes his fist at another client in a group meeting after the client speaks negatively of illicit drug use. The nurse quickly determines that the client is at risk to act violently against others as evidenced by his aggressive behavior, verbal threats, and a history of impulsivity. Which is the best approach for the nurse to use?
- A. Seclude the client to protect the other clients and staff.
- B. Put the client in restraints to protect the milieu.
- C. Explore alternate ways to handle frustrating topics in the group.
- D. Tell the client to leave the group until he can behave appropriately.
Correct Answer: C
Rationale: The correct answer is C: Explore alternate ways to handle frustrating topics in the group. This approach is best because it focuses on addressing the underlying issue causing the client's aggression rather than just isolating or restraining the client. By exploring alternate ways to handle frustrating topics, the nurse can help the client develop healthier coping mechanisms and communication skills. This approach promotes therapeutic engagement and supports the client's growth and development.
Secluding the client (choice A) may escalate the situation and reinforce the client's aggressive behavior. Putting the client in restraints (choice B) is a restrictive measure that should only be used as a last resort for imminent danger. Telling the client to leave the group (choice D) may not address the root cause of the aggression and could lead to avoidance of addressing the client's issues.