Nokea
The nurse is evaluating a patient with bulimia nervosa. The most appropriate action is to:
- A. Assign a strict dietary plan to prevent weight gain.
- B. Monitor the patient for physical symptoms of starvation.
- C. Encourage the patient to avoid purging after meals.
- D. Provide emotional support without focusing on food-related behaviors.
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to avoid purging after meals. This is the most appropriate action because it addresses the harmful purging behavior associated with bulimia nervosa. By encouraging the patient to avoid purging, the nurse can help prevent serious health consequences such as electrolyte imbalances and damage to the esophagus.
Option A is incorrect because assigning a strict dietary plan may exacerbate the patient's unhealthy relationship with food and contribute to feelings of guilt and shame. Option B is incorrect as monitoring for physical symptoms of starvation may not directly address the underlying issue of purging behavior. Option D is also incorrect as providing emotional support alone may not effectively address the harmful purging behavior.
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The patient on the mental health unit who should be assessed as being at highest risk for directing violent behavior toward others is the patient who has:
- A. Obsessive-compulsive disorder and performs many rituals.
- B. Paranoid delusions of being followed by the Mafia.
- C. Severe depression with feelings of worthlessness and self-loathing.
- D. Completed alcohol withdrawal and is now in a rehabilitation program.
Correct Answer: B
Rationale: The correct answer is B because paranoid delusions of being followed by the Mafia indicate a high level of suspiciousness and potential for harm to others. This patient may act out violently in self-defense or as a reaction to perceived threats. Choice A is incorrect as OCD rituals are typically not associated with violent behavior. Choice C is incorrect as severe depression is more likely to result in self-harm rather than harm towards others. Choice D is incorrect as completed alcohol withdrawal and entering a rehabilitation program do not inherently indicate an increased risk of violent behavior towards others.
Which information would be of greatest assistance to a nurse assessing a patient's motivation to change behavior associated with maladaptive eating regulation responses?
- A. The number, on a scale of 1 to 10, that reflects the patient's desire for treatment.
- B. The name of a person the patient feels he or she can rely on for emotional support.
- C. The advantages the patient identifies as motivation for controlling the maladaptive behavior.
- D. The reasons the patient identifies as the factors that originally caused the maladaptive behavior.
Correct Answer: A
Rationale: The correct answer is A because assessing the patient's desire for treatment provides insight into their readiness and motivation to change behavior. This information indicates their willingness to engage in the treatment process and is a key factor in predicting behavior change.
Option B is incorrect because relying on emotional support may not necessarily reflect the patient's motivation to change their behavior. Option C is incorrect as identifying advantages for controlling maladaptive behavior does not directly address the patient's motivation level. Option D is incorrect because understanding the factors that caused the behavior does not necessarily indicate the patient's current motivation to change.
A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
- A. Disturbed thought processes and Risk for other-directed violence
- B. Spiritual distress and Social isolation
- C. Risk for loneliness and Knowledge deficit
- D. Disturbed personal identity and Nonadherence
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence.
1. Disturbed thought processes: The patient's delusions (believing physicians are plotting to kill him) indicate disorganized thinking, a hallmark of paranoid schizophrenia.
2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violence towards others.
Incorrect choices:
B: Spiritual distress and Social isolation - Not directly related to the patient's current symptoms of paranoid delusions and threat of violence.
C: Risk for loneliness and Knowledge deficit - The patient's issues are more severe than loneliness or knowledge deficit.
D: Disturbed personal identity and Nonadherence - While these issues may be relevant in schizophrenia, they are not the primary concerns presented in this scenario.
An unusual state called 'waxy flexibility' is sometimes observed in schizophrenia
- A. borderline
- B. disorganized
- C. catatonic
- D. paranoid
Correct Answer: C
Rationale: Waxy flexibility, a motor symptom, is unique to catatonic schizophrenia.
A 17-year-old client who has anorexia nervosa states she believes she will have fewer problems in college and will be more popular if she continues to lose weight. What nursing intervention would be useful at this time?
- A. Assisting the client to identify the problems causing her concern.
- B. Determining what she hopes to gain from the behavior.
- C. Explaining that her chances for becoming ill from losing weight are high.
- D. Having a physical report sent to college officials indicating her condition.
Correct Answer: A
Rationale: The correct answer is A because it focuses on assisting the client to identify the problems causing her concern. By helping the client explore the underlying issues driving her desire to lose weight, the nurse can address the root cause of her behavior. This intervention promotes self-awareness and insight, enabling the client to better understand her motivations and make informed choices.
Option B is incorrect because while determining what the client hopes to gain from the behavior is important, it does not directly address the immediate concern of identifying underlying problems.
Option C is incorrect because simply explaining the risks of becoming ill may not effectively address the client's belief that losing weight will lead to fewer problems and increased popularity.
Option D is incorrect because sending a physical report to college officials without the client's consent may violate confidentiality and trust, and it does not address the client's psychological needs.