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The nurse is caring for a patient with anorexia nervosa. Which intervention is a priority?
- A. Establish a no-contact rule with the patient's family.
- B. Monitor the patient's food intake and weight closely.
- C. Encourage the patient to exercise to improve health.
- D. Focus primarily on addressing the patient's body image issues.
Correct Answer: B
Rationale: The correct answer is B because monitoring food intake and weight closely is crucial in managing anorexia nervosa to prevent further complications like malnutrition and dehydration. By closely monitoring these factors, the nurse can ensure the patient is receiving adequate nutrition and is not losing weight rapidly. Establishing a no-contact rule with the family (A) could hinder the patient's support system. Encouraging exercise (C) may worsen excessive calorie expenditure. Focusing on body image (D) is important but addressing immediate health risks takes precedence.
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A child, age 9, is being evaluated in the Emergency Department at the hospital. Her mother is with her and describes her as withdrawn and quiet. The nurse practitioner suspects child abuse. Which of these findings indicates that physical abuse may be a chronic problem for the child?
- A. The presence of the mother and her description of the child as withdrawn and quiet.
- B. The child's refusal to speak to the nurse.
- C. The child's physical appearance.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the mother's description of the child as withdrawn and quiet can indicate chronic physical abuse. This is because a child who is consistently withdrawn and quiet may be exhibiting signs of trauma from ongoing abuse. The mother's presence is also important as it provides insight into the child's home environment.
Explanation for why the other choices are incorrect:
B: The child's refusal to speak to the nurse may indicate shyness or fear, but it does not specifically point to chronic physical abuse.
C: The child's physical appearance alone does not provide enough information to determine if physical abuse is chronic.
In summary, choice A is the correct answer as it directly relates to potential signs of chronic physical abuse, while choices B and C do not provide sufficient evidence to support this conclusion.
A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?
- A. The patient is seeking the attention of staff.
- B. The patient is inappropriately expressing emotion.
- C. The patient is experiencing auditory hallucinations.
- D. The patient is displaying negative symptoms of schizophrenia.
Correct Answer: C
Rationale: The correct answer is C: The patient is experiencing auditory hallucinations. The patient's behavior of covering both ears and shaking her head as if responding to voices, along with muttering and crying, suggests a sensory perception that is not based on external stimuli. This aligns with the characteristic symptoms of auditory hallucinations, which are common in conditions like schizophrenia.
Choice A is incorrect because the patient's behavior is not necessarily seeking attention but rather responding to internal stimuli. Choice B is incorrect as the patient's emotional expression seems to be a result of the auditory hallucinations rather than being inappropriate. Choice D is incorrect as negative symptoms of schizophrenia typically involve a decrease or absence of normal functions, which is not clearly demonstrated in this scenario.
An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, 'It's awful to be old. Every day is a struggle. No one cares about old people.' Select the nurse's best response.
- A. Everyone here cares about old people. That's why we work here.
- B. It sounds like you're having a difficult time. Tell me about it.
- C. Let's not focus on the negative. Tell me something good.
- D. You are still able to get around, and your mind is alert.
Correct Answer: B
Rationale: The correct answer is B because it shows empathy and encourages the patient to express their feelings. By saying "Tell me about it," the nurse acknowledges the patient's struggle and opens up the opportunity for the patient to share more about their feelings and concerns. This can help build a therapeutic relationship and provide emotional support.
Choice A is incorrect because it dismisses the patient's feelings by making a general statement about everyone caring without addressing the patient's specific concerns.
Choice C is incorrect because it invalidates the patient's emotions by suggesting to focus on positivity without addressing the patient's current distress.
Choice D is incorrect because it minimizes the patient's struggle by only focusing on physical abilities and cognitive function without addressing the emotional aspect of the patient's statement.
The nurse who works in a sleep clinic knows that approximately ______% of adults suffer from insomnia.
- A. 10 to 20.
- B. 30 to 40.
- C. 50 to 60.
- D. 70 to 80.
Correct Answer: B
Rationale: The correct answer is B (30 to 40%). Insomnia is a common sleep disorder, affecting around 30-40% of adults. This range reflects the prevalence rates reported in various studies. Choices A, C, and D are incorrect because they provide prevalence rates that are either too low (A) or too high (C, D) compared to the generally accepted range for insomnia in adults. It is essential for the nurse in a sleep clinic to understand the prevalence of insomnia accurately to provide appropriate care and support to patients.
A patient, aged 77 years, has Alzheimer's disease and lives with her daughter. While checking her blood pressure at the clinic, the nurse noticed fresh bruises on the patient's palms and buttocks. The patient could not explain these bruises. The nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage. She stated, "My mother is getting worse every week. She is not my mother anymore. She can't recognize me, and she wanders all night. We take turns because she has to be watched constantly. Last night I fell asleep, and she fell down the stairs while wandering."Â Which statement is most accurate?
- A. Reporting the injuries in this case is not indicated by available data.
- B. The nurse should report the injuries as suggestive of elder abuse.
- C. The nurse is only required to report the injury if the patient is incompetent.
- D. The nurse is legally required to report the injuries as possible abuse.
Correct Answer: A
Rationale: Step 1: The nurse observed bruises on the patient's palms and buttocks.
Step 2: The patient could not explain these bruises.
Step 3: The daughter mentioned the patient's worsening condition and the incident of falling down the stairs.
Step 4: The daughter's statement indicates the patient's deteriorating cognitive and physical abilities.
Step 5: The daughter's challenges in managing the patient are due to the progression of Alzheimer's disease.
Step 6: There is no explicit evidence or indication of elder abuse based on the provided information.
Step 7: Reporting the injuries without clear signs of abuse may harm the patient's relationship with the daughter.
Step 8: Therefore, the most appropriate action is not to report the injuries based on the available data to avoid potential harm.
Summary:
- Choice A is correct as reporting the injuries is not indicated by the available data.
- Choices B, C, and D are incorrect as there is no clear evidence of elder abuse in the scenario