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What is the most appropriate initial treatment goal for a patient with anorexia nervosa?
- A. Achieve rapid weight gain to restore nutritional status.
- B. Restore the patient's nutritional balance through gradual weight gain.
- C. Focus on addressing body image issues before weight gain.
- D. Encourage the patient to participate in group therapy for support.
Correct Answer: B
Rationale: The correct initial treatment goal for a patient with anorexia nervosa is to restore the patient's nutritional balance through gradual weight gain. This approach is crucial as rapid weight gain can lead to refeeding syndrome, a potentially life-threatening complication. Gradual weight gain allows the body to adjust to increased caloric intake safely. Addressing body image issues is important but can be more effectively tackled after nutritional balance is restored. Group therapy can be beneficial but should not be the primary focus initially. Thus, choice B is the most appropriate initial treatment goal.
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Which assessment finding is most associated with bulimia nervosa?
- A. Prominent parotid glands
- B. Peripheral edema
- C. Thin, brittle hair
- D. Amenorrhea
Correct Answer: A
Rationale: The correct answer is A: Prominent parotid glands. This is associated with bulimia nervosa due to repeated vomiting, which can lead to enlargement of the parotid glands. This is known as parotid gland hypertrophy. The other choices (B: Peripheral edema, C: Thin, brittle hair, D: Amenorrhea) are more commonly associated with anorexia nervosa rather than bulimia nervosa. Edema is a sign of malnutrition in anorexia, while thin, brittle hair and amenorrhea are also common in anorexia due to severe weight loss and hormonal disturbances.
A patient is admitted to the inpatient unit with a diagnosis of schizophrenia. The patient has had episodes of school absenteeism, withdrawal from friends, and bizarre behavior, including talking to his or her 'keeper.' The psychiatric-mental health nurse's most appropriate response is to:
- A. acknowledge that the patient's perceptions seem real to him or her, and refocus the patient's attention on a task or activity
- B. encourage the patient to express his or her thoughts, to determine the meaning they have for the patient
- C. ignore the patient's bizarre behavior, because it will diminish after he or she has been given the correct medication
- D. inform the patient that his or her perceptions of reality have become distorted because of the illness
Correct Answer: A
Rationale: Validating the patient's experience while redirecting to reality-based activity builds trust and reduces agitation without confrontation.
Which of the following is a potential complication of untreated bulimia nervosa?
- A. Severe dehydration and electrolyte imbalances.
- B. Rapid weight gain and fluid retention.
- C. Chronic constipation and digestive issues.
- D. Severe malnutrition and organ failure.
Correct Answer: A
Rationale: The correct answer is A: Severe dehydration and electrolyte imbalances. Untreated bulimia nervosa involves recurrent episodes of binge-eating followed by compensatory behaviors like purging. Purging can lead to fluid loss and electrolyte imbalances, causing dehydration. This can result in serious health complications such as cardiac arrhythmias and kidney damage. Rapid weight gain and fluid retention (B) are more associated with binge-eating disorder, not bulimia nervosa. Chronic constipation and digestive issues (C) are more commonly seen in anorexia nervosa. Severe malnutrition and organ failure (D) are potential complications of anorexia nervosa rather than bulimia nervosa.
An appropriate intervention for a client with an identified nursing diagnosis of Situational low self-esteem would be:
- A. Encouraging verbalization of feelings in a safe environment
- B. Attempting to determine triggers to hallucinations
- C. Engaging client in activities designed to permit success
- D. Providing large muscle activities to relieve stress
Correct Answer: C
Rationale: The correct answer is C: Engaging client in activities designed to permit success. This intervention is appropriate for addressing situational low self-esteem as it focuses on building the client's self-confidence through successful experiences. Engaging in activities that the client can excel at helps boost self-esteem and self-worth. By providing opportunities for success, the client can gain a sense of accomplishment, leading to improved self-esteem.
A: Encouraging verbalization of feelings in a safe environment may be beneficial for emotional expression, but it does not directly address building self-esteem through success.
B: Attempting to determine triggers to hallucinations is unrelated to addressing situational low self-esteem.
D: Providing large muscle activities to relieve stress may be helpful for stress management but does not directly target improving self-esteem through success.
Which nursing intervention would be most helpful for addressing this behavior?
- A. Hold a weekly staff meeting to discuss feelings and conflicts related to such behavior.
- B. Confront the patient and advise her that if she continues this, she will lose privileges.
- C. Get all staff to agree that any and all inappropriate behavior will simply be ignored.
- D. Evaluate the patient for a medication increase or transfer to a long-term facility.
Correct Answer: A
Rationale: The correct answer is A because holding a weekly staff meeting to discuss feelings and conflicts related to the behavior promotes open communication and teamwork. This intervention allows staff to address the behavior in a collaborative and supportive manner, leading to a better understanding of the underlying issues and potential solutions.
Choice B is not the best option as confronting the patient may escalate the situation and create a power struggle, potentially worsening the behavior. Choice C of ignoring inappropriate behavior can lead to a lack of accountability and enable further misconduct. Choice D of evaluating the patient for a medication increase or transfer may not address the root cause of the behavior and could overlook the importance of addressing it through communication and teamwork.