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What is an appropriate goal for a nurse working with a patient with anorexia nervosa?
- A. The patient will gain weight rapidly to restore nutritional balance.
- B. The patient will express satisfaction with their body image by the end of treatment.
- C. The patient will eat three meals daily and demonstrate healthy eating behaviors.
- D. The patient will be able to resume normal physical activities without fatigue.
Correct Answer: C
Rationale: The correct answer is C because setting a goal for the patient to eat three meals daily and demonstrate healthy eating behaviors is a more realistic and achievable target for someone with anorexia nervosa. This goal focuses on establishing regular eating habits and promoting a healthy relationship with food, which are crucial in the treatment of anorexia nervosa. Choices A and D are incorrect as rapid weight gain and resuming normal physical activities may not be safe or sustainable goals for someone with anorexia nervosa. Choice B is also incorrect because body image satisfaction is a complex issue that may not be directly addressed solely through treatment for anorexia nervosa.
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A rape victim tells the emergency room nurse, "I feel so dirty. Help me take a shower before the doctor examines me."Â The nurse should:
- A. Arrange for the patient to shower.
- B. Explain that bathing would destroy evidence.
- C. Give the patient a basin of water and towels.
- D. Explain that bathing facilities are not available in the emergency department.
Correct Answer: B
Rationale: The correct answer is B: Explain that bathing would destroy evidence. This is the correct choice because bathing can potentially wash away crucial forensic evidence that can be collected during a sexual assault examination. Preserving evidence is essential for legal proceedings and ensuring justice for the victim.
Choice A is incorrect because arranging for the patient to shower would destroy evidence. Choice C is incorrect as giving the patient a basin of water and towels would still risk destroying evidence. Choice D is also incorrect as it does not address the importance of preserving evidence in cases of sexual assault.
A new client admits to having been battered by her live-in boyfriend several times over the past 2 years. She states to the nurse, 'We plan to get married next June, and I think things will be better then. He is always so sorry afterward, that I think I can trust him to change.' Which intervention should be included in the client's teaching plan?
- A. Support her hope that the battering will end after they are married.
- B. Assist her to enroll in a class to learn techniques of self-defense.
- C. Emphasize that the battering pattern usually remains the same in frequency and severity over time.
- D. Assist her in developing an emergency plan, since the pattern of violence is likely to continue.
Correct Answer: D
Rationale: The correct answer is D: Assist her in developing an emergency plan, since the pattern of violence is likely to continue. This choice is correct because it focuses on safety planning, which is crucial for individuals in abusive relationships. By helping the client develop an emergency plan, the nurse is acknowledging the seriousness of the situation and providing practical strategies to ensure her safety. It is important to have a plan in place in case of future violence.
Explanation for the incorrect choices:
A: Supporting her hope that the battering will end after they are married is not appropriate as it may give false hope and does not address the immediate safety concerns.
B: Enrolling in a self-defense class may not be effective in situations of domestic violence as it can escalate the violence and may not address the underlying issues causing the abuse.
C: Emphasizing that the battering pattern usually remains the same in frequency and severity over time is not as helpful as developing a concrete safety plan to address the immediate danger.
When planning inpatient psychotherapeutic activities for a patient who has antisocial personality disorder, the psychiatric-mental health nurse:
- A. focuses on group, rather than individual, therapy
- B. provides a permissive atmosphere, so the patient feels a sense of control
- C. provides an organized, structured environment
- D. recognizes that the disorder is characterized by social withdrawal
Correct Answer: C
Rationale: A structured environment sets clear boundaries, countering manipulative tendencies common in antisocial personality disorder.
A client frequently impulsively acts out suicidal impulses, including grabbing the coffee jar to smash it and attempting to hang herself with her bra. The nurse would view the client's behaviors as most consistent with:
- A. Narcissistic personality disorder
- B. Histrionic personality disorder
- C. Borderline personality disorder
- D. Antisocial personality disorder
Correct Answer: C
Rationale: The correct answer is C: Borderline personality disorder. The client's impulsive and self-destructive behaviors, such as attempting suicide, are characteristic of individuals with borderline personality disorder. These individuals often struggle with intense emotions, unstable relationships, and have a fear of abandonment. They may engage in self-harming behaviors as a way to cope with emotional distress.
A: Narcissistic personality disorder is characterized by a grandiose sense of self-importance and a lack of empathy. This does not align with the impulsive and self-destructive behaviors described in the scenario.
B: Histrionic personality disorder is characterized by attention-seeking behaviors and excessive emotions. While there may be some overlap with impulsive behaviors, it does not fully capture the severity and self-destructiveness of the client's actions.
D: Antisocial personality disorder is characterized by a disregard for the rights of others and a lack of remorse. While individuals with this disorder may engage in impulsive behaviors, the specific behaviors described in
When a person's sexual identity does not match his or her physical gender, the diagnosis is
- A. paraphilia
- B. sexual dysfunction
- C. gender identity disorder
- D. androgyny
Correct Answer: C
Rationale: Gender identity disorder (now gender dysphoria) describes a mismatch between identity and physical sex.