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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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Family members of a patient newly diagnosed with paranoid schizophrenia state that they do not understand what caused the patient's illness. The nurse's response should be predicated on the:
- A. Neurobiological-genetic model.
- B. Stress model.
- C. Family theory model.
- D. Developmental model.
Correct Answer: A
Rationale: The correct answer is A, the Neurobiological-genetic model, because paranoid schizophrenia is known to have a strong genetic component. Research has shown that individuals with a family history of schizophrenia are at a higher risk of developing the disorder. The neurobiological aspect refers to the abnormalities in brain structure and function associated with schizophrenia, such as neurotransmitter imbalances. Therefore, the nurse should educate the family members about the genetic predisposition and neurobiological factors contributing to the patient's illness.
Choices B, C, and D are incorrect:
B: The Stress model focuses on the role of environmental stressors in triggering or exacerbating mental illness, which is not the primary cause of paranoid schizophrenia.
C: The Family theory model emphasizes family dynamics and interactions as contributing factors to mental illness, but it is not the primary cause of paranoid schizophrenia.
D: The Developmental model looks at how early childhood experiences and developmental stages may influence mental health outcomes, but it is not the primary etiology of paranoid
A 35-year-old woman who is being interviewed by the advanced practice nurse indicates that she has few friends, fears criticism from others, and withholds information about her thoughts and feelings because she anticipates a negative reaction. Based on these data, the nurse suspects that Sarah may later be diagnosed as having:
- A. Borderline personality disorder
- B. Histrionic personality disorder
- C. Avoidant personality disorder
- D. Schizoid personality disorder
Correct Answer: C
Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, reluctance to share thoughts and feelings, and limited social interactions are characteristic of avoidant personality disorder. Individuals with this disorder have intense feelings of inadequacy, fear of rejection, and avoid situations where they may be criticized or judged.
Choice A: Borderline personality disorder is not the correct answer because individuals with borderline personality disorder typically have unstable relationships, impulsivity, and a fear of abandonment.
Choice B: Histrionic personality disorder is not the correct answer as individuals with this disorder seek attention and exhibit dramatic and attention-seeking behavior, which is not indicated in the scenario.
Choice D: Schizoid personality disorder is not the correct answer as individuals with this disorder tend to have a limited range of emotional expression and lack interest in forming social relationships, which does not align with the woman's fear of criticism and desire to avoid negative reactions.
A nurse is working with a family with an elderly family member who is in the predisgnostic phase of Alzheimer disease. The most important nursing intervention at this time would be to provide:
- A. family consultation to facilitate communication.
- B. information about support groups and counseling.
- C. options directed toward the reduction of caregiver stress.
- D. educational materials that help them understand their situation.
Correct Answer: D
Rationale: The correct answer is D because educating the family about Alzheimer's disease in the predisgnostic phase helps them understand what to expect and how to cope effectively. This empowers them to make informed decisions and provide appropriate care. Option A focuses on communication, which is important but not the most critical intervention at this stage. Option B is helpful but may not address the family's immediate needs. Option C addresses caregiver stress, which is important but may not be the priority in the predisgnostic phase. Therefore, providing educational materials is the most important intervention to support the family during this phase.
Some eating habits that seem to contribute to the incidence of cardiovascular disease are
- A. A diet that is high in fat
- B. A diet that is low in vegetables
- C. A diet that is low in fruits
- D. All of the above
Correct Answer: D
Rationale: High-fat, low-vegetable, and low-fruit diets all contribute to cardiovascular disease by increasing cholesterol and reducing nutrients.
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