Nokea
One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from:
- A. 150 to 102 pounds over a 4-month period.
- B. 120 to 90 pounds over a 3-month period.
- C. 130 to 100 pounds over a 2-month period.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the patient has experienced a significant weight drop from 150 to 102 pounds over a 4-month period. This represents a loss of 48 pounds over a relatively longer period, indicating a more severe and prolonged issue with weight loss. The other choices show weight drops of 30 pounds over 3 months (B) and 30 pounds over 2 months (C), which are also concerning but not as severe or long-lasting as the situation described in choice A. Choice D is incorrect as at least one patient should be admitted based on the information provided.
You may also like to solve these questions
An 83-year-old man becomes lost while driving. He pulls into a driveway to turn around and cannot figure out how to put his car in reverse, so he drives into the yard, makes a circle, and drives back out of the driveway. He is stopped by police, who take him to the emergency department. The physician diagnoses him with Alzheimer's disease and refers him to the neurology clinic for follow-up. Given this diagnosis, which behaviors should the clinic nurse anticipate?
- A. Does not know today's date.
- B. Unable to shower without help.
- C. Denial of mental impairment.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Does not know today's date. This behavior is commonly associated with Alzheimer's disease due to memory impairment. The inability to recall the current date is a key symptom of cognitive decline. In this case, the man's difficulty with reversing his car and getting lost are indicative of cognitive impairment.
Choice B, Unable to shower without help, is a functional impairment and not specific to Alzheimer's disease. Choice C, Denial of mental impairment, may occur in some individuals with Alzheimer's but is not a consistent behavior. Choice D, None of the above, is incorrect as memory deficits, such as not knowing the date, are commonly seen in Alzheimer's disease.
An expected outcome for a client who hears voices telling him he is evil would be that by discharge, client will:
- A. Verbalize the reason the voices say he is evil
- B. Respond verbally to the voices
- C. Identify events that increase anxiety and promote hallucinations
- D. Integrate the voices into his personality structure in a positive manner
Correct Answer: C
Rationale: The correct answer is C because it focuses on addressing the underlying causes of the client's experience of hearing voices and feeling evil. By identifying events that increase anxiety and promote hallucinations, the client can work on reducing these triggers and managing his symptoms effectively. This approach is key for long-term improvement and recovery.
A: Verbalizing the reason the voices say he is evil does not address the root cause of the hallucinations and may not lead to effective coping strategies.
B: Responding verbally to the voices may not be therapeutic and could potentially reinforce the hallucinations.
D: Integrating the voices into his personality structure in a positive manner is not a recommended approach as it could lead to further distress and potentially harmful behaviors.
A patient with schizophrenia tells the nurse, 'Everyone must listen to me. I am the redeemer. I will bring peace to the world.' From this the nurse can determine that an appropriate nursing diagnosis is:
- A. Disturbed sensory perception: auditory.
- B. Risk for other-directed violence.
- C. Chronic low self-esteem.
- D. Nonadherence: medication.
Correct Answer: C
Rationale: Step 1: The patient's statement indicates grandiosity and delusions of grandeur, common in schizophrenia.
Step 2: Chronic low self-esteem is a common nursing diagnosis for those with grandiose delusions.
Step 3: The patient's belief of being the redeemer suggests underlying feelings of inadequacy.
Step 4: Addressing self-esteem can help the patient cope with such delusions.
Summary: A is incorrect as there is no mention of auditory hallucinations. B is incorrect as there is no immediate threat of violence. D is incorrect as nonadherence to medication is not evident in the scenario.
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 severely depressed patient with psychomotor retardation has begun activities therapy. His schedule is: 9 AM, ceramics; 10 AM, exercise group; 11 AM to noon, open; noon, lunch. The nurse creating the patient's schedule should opt to fill the hour block from 11 AM to noon with:
- A. Group therapy.
- B. A rest period.
- C. Reminiscence group.
- D. Individual counseling.
Correct Answer: B
Rationale: The correct answer is B: A rest period. Providing a rest period during the hour block from 11 AM to noon is crucial for a severely depressed patient with psychomotor retardation. This patient may experience fatigue and decreased energy levels due to their condition. Allowing for a rest period can help prevent overstimulation and promote relaxation, which is essential for mental well-being. Group therapy (choice A) may be too overwhelming for the patient at this time. Reminiscence group (choice C) may not be as beneficial for immediate symptom management. Individual counseling (choice D) may be helpful but may not align with the patient's immediate need for rest and relaxation.