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What is the key component of treatment for a patient with anorexia nervosa?
- A. Encouraging rapid weight gain and exercise.
- B. Establishing a structured meal plan and emotional support.
- C. Restricting food intake to avoid further weight gain.
- D. Promoting independence and avoidance of therapy.
Correct Answer: B
Rationale: The correct answer is B because establishing a structured meal plan helps regulate eating behaviors and promotes nutrition restoration, while emotional support addresses underlying psychological issues. Rapid weight gain and exercise (A) can be harmful due to medical complications. Restricting food intake (C) worsens the condition. Promoting independence and avoiding therapy (D) hinder recovery by neglecting the importance of professional help.
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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.
A young, newly married adult says, 'My spouse never lets me out of sight. I'm not allowed to do anything on my own, and I'm constantly accused of cheating.' Which nursing communication is most therapeutic for this patient?
- A. Have you discussed the behavior with your spouse?'
- B. How does your spouse's behavior make you feel?'
- C. Are there other examples of controlling behaviors on your spouse's part?'
- D. Do you feel that your spouse has anything to be upset or suspicious about?'
Correct Answer: B
Rationale: The correct answer is B: "How does your spouse's behavior make you feel?" This question focuses on the patient's emotions, allowing them to express their feelings and validating their experiences. It shows empathy and encourages the patient to explore and understand their own emotional responses to the situation.
Choice A focuses on addressing the behavior directly without acknowledging the patient's emotions. Choice C asks for more examples of controlling behavior, which may feel judgmental. Choice D suggests that the spouse's behavior is justified, which can further invalidate the patient's feelings. Overall, choice B is the most therapeutic as it promotes emotional exploration and support.
A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, 'It's beat, it's eat. No room for doom.' The nurse can correctly assess this verbalization as:
- A. neologisms.
- B. clanging.
- C. ideas of reference.
- D. associative looseness.
Correct Answer: B
Rationale: The correct answer is B: clanging. Clanging refers to the pattern of speech characterized by the association of words based on sound rather than meaning. In this case, the patient's verbalization, "It's beat, it's eat. No room for doom," demonstrates a connection based on rhyming sounds rather than coherent meaning. This is a classic example of clanging commonly seen in individuals with disorganized schizophrenia. Neologisms (choice A) refer to new words created by the individual, ideas of reference (choice C) involve believing that external events have special significance for oneself, and associative looseness (choice D) pertains to a lack of logical connection between thoughts. These choices are incorrect as they do not accurately describe the patient's speech pattern in this scenario.
Children should undergo further evaluation when their weight is % above their height.
- A. 10
- B. 15
- C. 20
- D. 25
Correct Answer: C
Rationale: The correct answer is C (20%). This is because a weight that is 20% above a child's height can indicate potential health issues such as obesity. Excess weight can lead to various health problems in children. Choices A, B, and D are incorrect as they represent lower percentages, which may not be as concerning in terms of potential health risks. It is important to consider a higher percentage threshold for further evaluation to ensure early detection and intervention for any weight-related issues.
Which statements most clearly indicate the speaker views mental illness with stigma? Select one tha does not apply.
- A. We are all a little bit crazy.'
- B. If people with mental illness would go to church, their problems would be solved.'
- C. Many mental illnesses are genetically transmitted. Its no ones fault that the illness occurs.'
- D. People with mental illness are lazy. They get government disability checks instead of working.'
Correct Answer: C
Rationale: Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame.