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The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:
- A. Level of consciousness
- B. Ability to perform activities of daily living
- C. Degree of reasoning, judgment, and thought processes
- D. Level of functioning memory
Correct Answer: B
Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.
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A nurse is working with a patient with bulimia nervosa. Which outcome would indicate successful intervention?
- A. The patient eats three full meals daily without purging.
- B. The patient agrees to begin psychotherapy without resistance.
- C. The patient loses 5% of their body weight over 3 months.
- D. The patient expresses improved body image but still purges occasionally.
Correct Answer: A
Rationale: The correct answer is A because it indicates successful intervention in bulimia nervosa by demonstrating healthy eating behavior without purging. This outcome reflects improved control over binge-purge cycles and supports physical health. Choices B and D show progress but do not directly address the core issue of purging behavior. Choice C, losing weight, can be a misleading indicator and may not necessarily reflect improved psychological and behavioral outcomes associated with recovery from bulimia nervosa.
A 79-year-old white male tells a nurse, 'I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.' The nurse should analyze this comment as
- A. normal pessimism of the elderly.
- B. evidence of risks for suicide.
- C. a call for sympathy.
- D. normal grieving.
Correct Answer: B
Rationale: The correct answer is B: evidence of risks for suicide. The elderly man's statement indicates feelings of hopelessness, loneliness, and lack of purpose, which are common risk factors for suicide in older adults. The nurse should assess further for suicidal ideation and intervene accordingly.
Choice A is incorrect because the statement goes beyond normal pessimism by expressing thoughts of not having much to live for. Choice C is incorrect as the statement is more indicative of distress rather than a mere call for sympathy. Choice D is incorrect as normal grieving typically involves processing emotions related to a specific loss, whereas the man's statement reflects a broader sense of despair.
Which finding is most indicative of refeeding syndrome in a patient with anorexia nervosa?
- A. Increased energy and mental clarity after eating.
- B. Electrolyte imbalances, particularly hypophosphatemia.
- C. A sudden increase in appetite and food cravings.
- D. Rapid weight gain and hypertension.
Correct Answer: B
Rationale: The correct answer is B because refeeding syndrome is characterized by electrolyte imbalances, especially hypophosphatemia, due to rapid reintroduction of nutrition. This can lead to serious complications like cardiac arrhythmias and respiratory failure. Increased energy and mental clarity (A) are not specific to refeeding syndrome. A sudden increase in appetite and food cravings (C) may occur but are not indicative of refeeding syndrome. Rapid weight gain and hypertension (D) are not typically seen in refeeding syndrome.
A male patient diagnosed with paranoid schizophrenia typically relates effectively with female staff but angrily tells the male nurse, 'You act like a homosexual. None of the men trust you or want to be around you.' The nurse, who is heterosexual, is perplexed by the patient's statements and discusses the event with his mentor. Which explanation most likely underlies the patient's behavior?
- A. The patient was unleashing unconscious, hostile feelings toward the nurse.
- B. The patient feared the nurse would reject him, so he coped by rejecting the nurse first.
- C. It was the patient's way of distancing himself from potential emotional intimacy.
- D. The patient was coping with homosexual urges by projecting them onto the nurse.
Correct Answer: D
Rationale: The correct answer is D because the patient's accusation of the nurse being homosexual and implying that other men do not trust him or want to be around him suggests projection of the patient's own homosexual urges onto the nurse. This defense mechanism of projection helps the patient avoid acknowledging and dealing with his own uncomfortable feelings by attributing them to someone else.
Option A is incorrect because the patient's behavior is more about projecting feelings onto the nurse rather than unconscious hostility. Option B is incorrect as it focuses on the patient's fear of rejection rather than projecting his own feelings onto the nurse. Option C is incorrect as it does not address the specific dynamic of projecting homosexual urges onto the nurse.
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B: Assess for lower extremity edema bid. It is important to assess for lower extremity edema in this client with catatonic schizophrenia as posturing in a standing position for prolonged periods can lead to decreased circulation and potential development of edema. This assessment is crucial to monitor the client's physical health and prevent complications such as deep vein thrombosis.
Choice A is incorrect as insisting the client sit or lie down for 30 minutes hourly may not address the underlying issue of potential lower extremity edema and could potentially worsen the client's condition by causing distress.
Choice C is incorrect as providing high-calorie drinks hourly does not address the immediate physical health concern of lower extremity edema and may not be appropriate without a comprehensive assessment of the client's nutritional needs.
Choice D is incorrect as taking the client to activities therapy once daily does not address the immediate need for assessing lower extremity edema and may not be suitable if the client's physical health