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What is the most important goal for a nurse when providing care for a patient with bulimia nervosa?
- A. To promote weight loss through strict dietary control.
- B. To help the patient eliminate purging behaviors and develop healthy eating habits.
- C. To encourage excessive exercise to balance caloric intake.
- D. To focus solely on addressing body image issues.
Correct Answer: B
Rationale: The correct answer is B: To help the patient eliminate purging behaviors and develop healthy eating habits. This goal is important because it addresses the core issues of bulimia nervosa, which are unhealthy purging behaviors and distorted eating patterns. By helping the patient stop purging and establish healthy eating habits, the nurse can promote long-term recovery and overall well-being.
Choice A is incorrect because promoting weight loss through strict dietary control can exacerbate the patient's unhealthy relationship with food and body image. Choice C is incorrect as encouraging excessive exercise can contribute to a cycle of compulsive behaviors and worsen the patient's physical and mental health. Choice D is incorrect because focusing solely on body image issues neglects the underlying psychological factors contributing to bulimia nervosa.
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Schizophrenia is usually diagnosed in:
- A. Infancy
- B. Childhood
- C. Early adulthood
- D. Old age
Correct Answer: C
Rationale: Schizophrenia typically emerges in early adulthood (late teens to early 20s), though symptoms may appear earlier or later in rare cases.
Which is the most appropriate initial goal for a nurse when attempting to overcome personal negative attitudes about a patient who has a history of returning to an abusive spouse?
- A. Exploring own attitudes and values toward survivors of violence
- B. Identifying the dysfunctional behaviors exhibited by the violent family
- C. Concentrating on identifying any possible personal abusive relationships
- D. Attending seminars on the psychological impact of being the victim of abuse
Correct Answer: A
Rationale: The correct answer is A because exploring one's own attitudes and values towards survivors of violence is crucial in overcoming personal negative attitudes. By reflecting on personal biases, the nurse can gain self-awareness and empathy, enabling better care for the patient. Choice B is incorrect as it focuses on the abuser's behaviors, not the nurse's attitudes. Choice C is incorrect as it shifts the focus to the nurse's personal relationships. Choice D is incorrect as attending seminars does not directly address the nurse's personal attitudes.
A woman has been severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, has no financial resources of her own, and has no job skills. Which would be the most important referral for the nurse to make?
- A. Community food cupboard
- B. Vocational counseling
- C. Law enforcement
- D. Safe house or shelter
Correct Answer: D
Rationale: The correct answer is D: Safe house or shelter. This option is the most important referral because the woman is in immediate danger and needs a safe place to stay away from her abusive husband. It prioritizes her safety and well-being. Referring her to a safe house can provide her with protection, resources, and support to help her escape the abusive situation.
Choice A (Community food cupboard) is incorrect as it does not address the woman's immediate safety needs. Choice B (Vocational counseling) is also not the most urgent referral in this situation as the woman's safety should be the priority. Choice C (Law enforcement) might be necessary in the long run, but the immediate concern is ensuring the woman's safety by referring her to a safe house or shelter.
Which of the following are considered red flags for a communication disorder?
- A. Speech onset at 24 months, lack of pointing to indicate needs, and poor eye contact
- B. Short attention, odd intonation of speech, and poor pretend play
- C. Lack of pointing to show interests or needs, poor eye contact, and reduced joint attention
- D. Weak vocabulary, reduced joint attention, and poor interaction with peers
Correct Answer: C
Rationale: Red flags for communication disorders include lack of pointing to show interests/needs, poor eye contact, and reduced joint attention, as these indicate deficits in social communication, per developmental guidelines.
The spouse of a man being treated with sertraline (Zoloft) calls to report that he had a grand mal seizure. Prior to the seizure, he had seemed confused and his forehead felt hot. The man does not have a seizure-disorder history. Which action should the nurse direct the spouse to take?
- A. Monitor the patient and notify the clinic if there are more seizures.
- B. Hold all medications and call 911 for transportation to the hospital.
- C. Hold tonight's sertraline and encourage him to drink more fluids.
- D. Administer an antipyretic drug to lower his fever and prevent seizures.
Correct Answer: B
Rationale: Step 1: The man had a grand mal seizure, confusion, and a hot forehead, which are signs of serotonin syndrome, a serious side effect of sertraline.
Step 2: The nurse should direct the spouse to hold all medications to prevent further serotonin syndrome symptoms.
Step 3: Calling 911 for immediate transportation to the hospital is crucial for prompt evaluation and treatment of the seizure and serotonin syndrome.
Step 4: This action ensures the man receives appropriate medical care to address the seizure and manage the potential serotonin syndrome.
Summary:
- Choice A is incorrect as monitoring the patient at home is not sufficient for a serious medical emergency like serotonin syndrome.
- Choice C is incorrect as simply holding tonight's sertraline and encouraging fluids does not address the immediate need for medical intervention.
- Choice D is incorrect as administering an antipyretic drug does not address the underlying cause of the seizure and confusion, which is serotonin syndrome.