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What is the first intervention a nurse should take when assessing a patient with suspected anorexia nervosa?
- A. Begin refeeding to restore nutritional status.
- B. Measure vital signs to assess the extent of malnutrition.
- C. Start a counseling session to discuss the patient's thoughts on eating.
- D. Involve the family in discussions about treatment plans.
Correct Answer: B
Rationale: The correct answer is B. The first intervention a nurse should take when assessing a patient with suspected anorexia nervosa is to measure vital signs to assess the extent of malnutrition. This is crucial to determine the patient's current physiological status and to identify any immediate risks such as dehydration, electrolyte imbalances, or cardiac complications. By measuring vital signs, the nurse can quickly assess the severity of malnutrition and determine the urgency of intervention. Refeeding (choice A) should not be initiated abruptly due to the risk of refeeding syndrome. Starting a counseling session (choice C) may be important but is not the initial priority. Involving the family (choice D) can be beneficial but is not the first step in assessing and managing a patient with anorexia nervosa.
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A severely depressed patient with psychomotor retardation has begun activities therapy. His schedule is: 9 AM, ceramics; 10 AM, exercise group; 11 AM to noon, open; noon, lunch. The nurse creating the patient's schedule should opt to fill the hour block from 11 AM to noon with:
- A. Group therapy.
- B. A rest period.
- C. Reminiscence group.
- D. Individual counseling.
Correct Answer: B
Rationale: The correct answer is B: A rest period. Providing a rest period during the hour block from 11 AM to noon is crucial for a severely depressed patient with psychomotor retardation. This patient may experience fatigue and decreased energy levels due to their condition. Allowing for a rest period can help prevent overstimulation and promote relaxation, which is essential for mental well-being. Group therapy (choice A) may be too overwhelming for the patient at this time. Reminiscence group (choice C) may not be as beneficial for immediate symptom management. Individual counseling (choice D) may be helpful but may not align with the patient's immediate need for rest and relaxation.
A community health nurse is working with a family in which an elderly woman was neglected by her son and his wife. The elderly woman insists on remaining with the young couple despite the threat of future neglect. Which intervention should be given highest priority?
- A. Identify community resources to decrease the caregivers' stress.
- B. Establish family obligations, client rights, and consequences of abuse and monitor.
- C. Educate the caregivers on the aging process and how to cope with it.
- D. Provide stress management techniques for the caregivers.
Correct Answer: B
Rationale: The correct answer is B because establishing family obligations, client rights, and consequences of abuse is crucial in protecting the elderly woman from neglect. By setting clear boundaries and educating the family on their responsibilities and the consequences of neglect, the nurse can help ensure the woman's safety. This intervention addresses the root cause of the issue and empowers the family to understand and fulfill their duties.
Choice A is incorrect as solely focusing on decreasing caregivers' stress may not address the underlying neglect. Choice C is incorrect as educating caregivers on the aging process does not directly address the neglect issue. Choice D is incorrect as providing stress management techniques does not address the root cause of neglect or establish accountability within the family.
A psychotic patient is delusional and has auditory hallucinations. The best statement to make when approaching the patient with an oral electronic thermometer would be:
- A. I need your vital signs. Put this in your mouth. This will not hurt.'
- B. I hope I can count on you to hold still while I take your temperature.'
- C. Please sit here while I take your temperature. I'll put the thermometer under your tongue for a few seconds.'
- D. This probe is only a thermometer that will tell us whether you have a fever. It will be all over in just a few seconds.'
Correct Answer: C
Rationale: The correct answer is C because it uses clear, simple language to explain the procedure to the patient. It acknowledges the patient's delusions by asking them to sit and calmly states the thermometer will be placed under their tongue. This approach is likely to minimize the patient's anxiety and increase cooperation.
Option A is incorrect as it may cause the patient to feel apprehensive due to the mention of "hurt." Option B is incorrect because it does not provide specific instructions about the procedure, which may lead to confusion for the patient. Option D is incorrect as it does not address the patient's delusions or provide clear instructions, potentially leading to increased resistance from the patient.
Many clients with eating disorders have difficulty translating their pain into words. Which approach may be used to promote getting in touch with feelings and greater self-disclosure?
- A. Personality inventory testing.
- B. Dance and movement therapy.
- C. Letter writing.
- D. Cooking and meal-planning classes.
Correct Answer: B
Rationale: The correct answer is B: Dance and movement therapy. This approach can help clients with eating disorders express emotions non-verbally, promoting self-awareness and self-disclosure. Movement therapy encourages embodied expression of feelings, facilitating a deeper connection to internal experiences. It allows clients to explore and release emotions through physical movement, aiding in the processing of emotional pain. Personality inventory testing (A) may not directly address emotional expression. Letter writing (C) can help, but may not be as effective as movement in promoting non-verbal expression. Cooking and meal-planning classes (D) focus on practical skills rather than emotional expression.
A mother discusses her concerns about genetic transmission of schizophrenia with the nurse saying, 'My son is a fraternal twin. He has been diagnosed with schizophrenia. Will my other son develop schizophrenia, too?' The response that is both sensitive and shows understanding of the genetic component is:
- A. You poor woman! I wish I could tell you he will be free of the disorder.'
- B. Studies show that 50% of twins develop schizophrenia when it is present in the other twin.'
- C. No one can say what will happen, so we will hope for the best for you and your sons.'
- D. In fraternal twins, the chance of the other twin developing the disorder is quite small.'
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate and sensitive response. Fraternal twins do not share the same genetic makeup as identical twins, so the genetic risk for the other twin developing schizophrenia is lower. By acknowledging this fact, the nurse offers reassurance to the mother without giving false hope or inaccurate statistics. This response shows understanding of the genetic component of schizophrenia and addresses the mother's concerns in a compassionate and informative manner.
Choices A, B, and C are incorrect:
A: This response is dismissive of the mother's concerns and does not provide any helpful information. It also lacks sensitivity and empathy towards the mother's situation.
B: This response provides an inaccurate statistic about the likelihood of the other twin developing schizophrenia. It does not consider the difference between identical and fraternal twins, leading to a potentially misleading statement.
C: This response is vague and does not address the mother's question directly. It does not provide any useful information or reassurance, leaving the mother uncertain and anxious about