Age Specific Care Quiz

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What is the most important aspect of nursing care for patients with anorexia nervosa during refeeding?

  • A. Refeed the patient with high-calorie foods quickly to gain weight.
  • B. Start with small, manageable portions and gradually increase caloric intake.
  • C. Restrict food choices to healthy foods only.
  • D. Encourage the patient to take food supplements in addition to meals.
Correct Answer: B

Rationale: The correct answer is B: Start with small, manageable portions and gradually increase caloric intake. This approach is essential because refeeding syndrome can occur in patients with anorexia nervosa, where rapid refeeding can lead to severe electrolyte imbalances and potentially life-threatening complications. Starting with small portions helps to prevent this syndrome by allowing the body to gradually adjust to increased caloric intake. Additionally, it helps in preventing overwhelming the patient with large amounts of food, which can trigger anxiety and resistance to eating.

Incorrect choices:
A: Refeed the patient with high-calorie foods quickly to gain weight - This can lead to refeeding syndrome and is not a safe approach.
C: Restrict food choices to healthy foods only - Restricting food choices can exacerbate disordered eating behaviors and does not address the need for gradual refeeding.
D: Encourage the patient to take food supplements in addition to meals - While supplements can be helpful, they should not be a primary focus over balanced

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A patient with swelling and a laceration above the right eye states, 'I don't know what caused me to fall and cut my head on the door frame in my bedroom. I'm lucky my spouse was home to take me to the hospital.' The patient's spouse appears nervous but smiles when mentioning that the patient is 'so clumsy at times.' Which nursing intervention should the nurse give priority attention to when addressing this patient's needs?

  • A. Provide a thorough assessment that includes a focus on signs of old injuries.
  • B. Interview the patient regarding the circumstances surrounding this suspicious fall.
  • C. Directly ask the patient if spousal abuse is occurring or has ever occurred.
  • D. Notify security that there is a possibility that this patient is a victim of physical abuse.
Correct Answer: A

Rationale: The correct answer is A: Provide a thorough assessment that includes a focus on signs of old injuries. This is the priority intervention because the patient's statement, combined with the spouse's behavior, raises suspicion of potential domestic abuse. By assessing for signs of old injuries, the nurse can gather crucial information to determine if the patient is a victim of abuse.

Choice B: Interview the patient regarding the circumstances surrounding this suspicious fall may be important, but assessing for signs of old injuries takes priority as it provides concrete evidence of potential abuse.

Choice C: Directly ask the patient if spousal abuse is occurring or has ever occurred is necessary, but the patient may not feel comfortable disclosing abuse directly. Assessing for old injuries can provide objective evidence.

Choice D: Notify security that there is a possibility that this patient is a victim of physical abuse is premature without concrete evidence. Assessing for old injuries should be done first to gather information before taking further action.

A man who regularly experiences premature ejaculation tells the nurse, 'I feel like such a failure. It's so awful for both me and my partner.' Select the nurse's most therapeutic response.

  • A. I sense you are feeling frustrated and upset.
  • B. Tell me more about feeling like a failure.
  • C. You are too hard on yourself.
  • D. What do you mean by awful?
Correct Answer: A

Rationale: The correct answer is A because it acknowledges the man's emotions of frustration and upset, showing empathy and understanding. This response validates his feelings and opens the door for further discussion. Choice B shifts the focus away from the man's current emotions. Choice C minimizes his feelings and may come across as dismissive. Choice D is too vague and doesn't address the man's emotional state directly. Overall, choice A is the most therapeutic as it validates the man's feelings and encourages him to express more.

The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:

  • A. Level of consciousness
  • B. Ability to perform activities of daily living
  • C. Degree of reasoning, judgment, and thought processes
  • D. Level of functioning memory
Correct Answer: B

Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.

A nurse monitors a patient with anorexia nervosa for complications of refeeding. Which assessment is most important?

  • A. Pupillary reaction to light
  • B. Temperature measurements
  • C. Reports of serum electrolytes
  • D. Complaints of sleep disturbances
Correct Answer: C

Rationale: The correct answer is C, reports of serum electrolytes. In anorexia nervosa, refeeding syndrome can occur, leading to electrolyte imbalances. Monitoring serum electrolytes is crucial to prevent complications like cardiac arrhythmias and seizures. Pupillary reaction, temperature, and sleep disturbances are important but not as critical as assessing electrolyte levels in this scenario.

A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, 'Without the red teddies, I am not interested in sex.' The nurse can assess this as consistent with

  • A. exhibitionism.
  • B. voyeurism.
  • C. frotteurism.
  • D. fetishism.
Correct Answer: D

Rationale: The correct answer is D: fetishism. Fetishism is a sexual disorder where a person is sexually aroused by an object or body part that is not typically considered sexual. In this scenario, the patient's arousal is dependent on his wife wearing a specific type of clothing (the red camisole-style nightgowns), indicating a fetishistic preference for that particular item. This is different from exhibitionism (A), which involves exposing one's genitals to unsuspecting strangers; voyeurism (B), which involves observing unsuspecting individuals undressing or engaging in sexual activity; and frotteurism (C), which involves touching or rubbing against a non-consenting person for sexual arousal.

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