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What is the most appropriate goal for a nurse caring for a patient with anorexia nervosa?
- A. The patient will gain weight rapidly to achieve a normal weight.
- B. The patient will stabilize their weight and maintain adequate nutrition.
- C. The patient will achieve full recovery without needing additional support.
- D. The patient will accept their body image as normal and healthy.
Correct Answer: B
Rationale: The most appropriate goal for a nurse caring for a patient with anorexia nervosa is for the patient to stabilize their weight and maintain adequate nutrition (Choice B). This goal is crucial because rapid weight gain can have negative physical and psychological consequences for the patient. Stabilizing weight helps prevent complications like refeeding syndrome and supports the patient's overall health. It also addresses the immediate nutritional needs of the patient. Choices A, C, and D are incorrect because rapid weight gain can be harmful, full recovery often requires ongoing support, and body image acceptance may not be the most pressing concern for someone with anorexia nervosa.
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A frequent finding in clients with Paraphiliac sexual disorders is that they have:
- A. Other covert or overt emotional
- B. Gonadal and pituitary hormone deficiencies
- C. An inadequate physical development of the sex organs
- D. A poor adjustment due to association with society's fringe groups
Correct Answer: A
Rationale: Clients with paraphilic disorders often have coexisting emotional disorders, which may contribute to or result from their condition.
In most anxiety disorders, the person's distress is
- A. focused on a specific situation
- B. related to ordinary life stresses
- C. greatly out of proportion to the situation
- D. based on a physical cause
Correct Answer: C
Rationale: Anxiety disorders feature exaggerated distress disproportionate to the trigger, unlike normal stress.
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A: Asking about trust in the nurse is not immediately relevant as the patient's primary concern is the change in voice content. Building trust is important but addressing the content of hallucinations takes priority.
B: This is relevant as commanding voices could pose a safety risk.
C: Monitoring frequency helps assess severity and response to treatment.
D: Understanding triggers for hallucinations is important for managing symptoms.
A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively.
- A. Would you say your mood is often sad?
- B. Are you having any trouble with your memory?
- C. Have you noticed an increase in your alcohol use?
- D. Do you often experience moderate to severe pain?
Correct Answer: A
Rationale: The correct answer is A because assessing the patient's mood is crucial in detecting depression in the elderly. Depression is common in older adults and can often go undiagnosed. By asking about their mood, the nurse can identify potential signs of depression early on. Choices B, C, and D are incorrect as they do not directly relate to assessing depression. Memory issues (B) may indicate cognitive decline, increased alcohol use (C) could suggest substance abuse, and pain (D) may signal physical health concerns, but they are not specific indicators of depression in the elderly.
Marie is 16 years old. She has been referred to the clinic by the nurse at her school because she started a fight with a younger girl and hurt her badly. The school nurse reports that Marie has been troublesome beforeskipping school, bullying, and smoking on school grounds on several occasions. Of the following, which diagnosis is most likely?
- A. Bipolar depression
- B. Paranoid schizophrenia
- C. Conduct disorder
- D. Dysthymic disorder
Correct Answer: C
Rationale: Conduct disorder is characterized by a pattern of aggressive behavior and violating the rights of others, including defiance and rule breaking. The other responses are psychiatric disorders that would not be the most likely diagnosis given Maries behavior.