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What is the correct assessment for a patient with bulimia nervosa who frequently engages in purging behaviors?
- A. Observe for parotid gland enlargement and dehydration.
- B. Assess for fluid retention and leg swelling.
- C. Perform regular weight checks to assess for weight loss.
- D. Evaluate for signs of hyperactivity and poor sleep.
Correct Answer: A
Rationale: The correct assessment for a patient with bulimia nervosa who frequently engages in purging behaviors is to observe for parotid gland enlargement and dehydration. Parotid gland enlargement is a common physical manifestation due to repeated vomiting, and dehydration can result from purging behaviors. This assessment is crucial in monitoring the patient's physical health and identifying potential complications. Assessing for fluid retention and leg swelling (Choice B) is more typical in conditions like heart failure. Performing weight checks (Choice C) may not accurately reflect the patient's health status due to fluid shifts. Evaluating for signs of hyperactivity and poor sleep (Choice D) are not directly related to the immediate physical consequences of purging behaviors.
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An advance directive gives legally binding direction for health care interventions when a patient:
- A. has a new diagnosis of cancer
- B. is diagnosed with Parkinsons disease
- C. is unable to make decisions for self because of illness
- D. diagnosed with amyotrophic lateral sclerosis is unable to speak
Correct Answer: C
Rationale: Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinsons disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.
A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
- A. aloofness, increased distractibility, and suspicion.
- B. elevated mood, hypertalkativeness, and distractibility.
- C. performing rituals and avoiding open places.
- D. darting eyes, distracted, and mumbling to self.
Correct Answer: D
Rationale: The correct answer, D, is indicative of auditory hallucinations. Darting eyes may suggest that the patient is hearing voices, distracted behavior aligns with responding to internal stimuli, and mumbling to oneself could be a response to hearing voices. Choices A, B, and C do not directly relate to auditory hallucinations, as they are more indicative of other mental health symptoms such as social withdrawal, mania, anxiety, or compulsive behaviors. Selecting D helps identify potential auditory hallucinations based on observed behaviors associated with hearing voices.
Which activity best supports cognitive growth in infants?
- A. Listening to music
- B. Tummy time
- C. Reading aloud
- D. Watching TV
Correct Answer: C
Rationale: Reading aloud (C) stimulates language acquisition and cognitive connections in infants. Music (A) and tummy time (B) aid development, but reading has a stronger cognitive impact. TV (D) is less interactive and less beneficial.
What is the primary nursing concern for a patient with anorexia nervosa during the early stages of treatment?
- A. Ensuring rapid weight gain to restore health.
- B. Addressing the patient's psychological issues related to body image.
- C. Maintaining nutritional intake to prevent further weight loss.
- D. Promoting self-esteem and body image satisfaction.
Correct Answer: C
Rationale: The primary nursing concern for a patient with anorexia nervosa in the early stages of treatment is maintaining nutritional intake to prevent further weight loss. This is crucial as malnutrition can lead to serious health complications. Ensuring adequate nutrition supports physical health and provides a foundation for addressing psychological issues in later stages of treatment. Rapid weight gain (A) can be harmful and lead to refeeding syndrome. Addressing psychological issues (B) and promoting self-esteem (D) are important but secondary concerns once nutritional stability is achieved.
The nursing diagnosis most likely to be used for a person who has a diagnosis of schizophrenia, paranoid type, is:
- A. social isolation related to impaired ability to trust.
- B. impaired mobility related to fear of losing control of hostile impulses.
- C. fear of being alone related to lack of confidence in significant others.
- D. impaired memory related to poor information processing associated with brain deficits.
Correct Answer: A
Rationale: Step-by-step rationale for choice A:
1. Schizophrenia, paranoid type, involves mistrust and suspicion.
2. Impaired ability to trust can lead to social isolation.
3. "Impaired ability to trust" directly relates to social isolation.
4. Therefore, "social isolation related to impaired ability to trust" is the most likely nursing diagnosis.
Summary of other choices:
- B: Not directly related to mistrust in paranoid schizophrenia.
- C: Lack of confidence in significant others is not a defining characteristic of paranoid schizophrenia.
- D: Impaired memory is not a primary feature of paranoid schizophrenia.