Nokea
What is the primary concern when a patient with bulimia nervosa engages in frequent purging?
- A. Electrolyte imbalances and dehydration.
- B. Increased risk of obesity and metabolic syndrome.
- C. Improvement in body image and self-esteem.
- D. Decreased risk of gastrointestinal complications.
Correct Answer: A
Rationale: The correct answer is A: Electrolyte imbalances and dehydration. Purging behaviors in bulimia nervosa, such as self-induced vomiting or laxative abuse, can lead to electrolyte imbalances and dehydration due to loss of essential minerals and fluids. This can result in serious medical complications like cardiac arrhythmias and kidney damage. The other choices are incorrect because B is unrelated to purging behaviors, C is unlikely as purging does not improve body image or self-esteem, and D is incorrect as purging actually increases the risk of gastrointestinal complications.
You may also like to solve these questions
A nurse caring for a patient with bulimia nervosa should teach the patient about:
- A. Self-monitoring of daily food and fluid intake.
- B. Establishing the desired daily weight gain.
- C. Symptoms of hypokalemia.
- D. Self-esteem maintenance.
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
1. Patients with bulimia nervosa often engage in purging behaviors, leading to electrolyte imbalances.
2. Hypokalemia is a common complication due to vomiting, which can have serious consequences.
3. Educating the patient about hypokalemia symptoms is crucial for early detection and intervention to prevent complications.
Summary of Incorrect Choices:
A. Self-monitoring of food intake is important but not the priority as addressing electrolyte imbalances.
B. Weight gain is not a recommended goal for patients with bulimia nervosa.
D. While self-esteem maintenance is important, addressing acute physical health risks takes precedence.
A nurse is caring for a patient with bulimia nervosa who is experiencing frequent purging. What is a priority assessment?
- A. Monitor electrolyte levels and cardiac function.
- B. Observe for signs of dehydration and low blood pressure.
- C. Assess for any compulsive exercise behaviors.
- D. Monitor for changes in eating patterns and food preferences.
Correct Answer: A
Rationale: The correct answer is A, to monitor electrolyte levels and cardiac function. This is a priority assessment because frequent purging in bulimia nervosa can lead to electrolyte imbalances and cardiac complications, such as arrhythmias and heart failure. Monitoring these parameters is crucial for early detection and intervention to prevent serious health consequences. Observing for signs of dehydration and low blood pressure (Choice B) is important but not as critical as monitoring electrolyte levels and cardiac function. Assessing for compulsive exercise behaviors (Choice C) and monitoring changes in eating patterns and food preferences (Choice D) are also relevant but secondary to the immediate risk of electrolyte imbalances and cardiac issues.
You are a nurse meeting for the first time with a stage 3 Alzheimer's patient who is newly referred to your home health agency. Which assessment data about the patient and caregiver(s) would be most important to acquire during your first visit to the family's home?
- A. Is the house design such that patient access to exits and stairways can be restricted?
- B. Does the family understand that the disease is likely to prove fatal within 3 to 5 years?
- C. What resources is the patient's family able to access in their particular community?
- D. What activities or memories are most comforting and calming for the patient?
Correct Answer: A
Rationale: Step 1: Ensuring patient safety is the top priority in caring for a stage 3 Alzheimer's patient in a home setting.
Step 2: Restricting access to exits and stairways is crucial to prevent the patient from wandering or falling.
Step 3: This assessment data is essential for implementing safety measures and preventing potential harm to the patient.
Step 4: Choices B, C, and D, while important, do not directly address the immediate safety concerns of the patient.
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
- A. Are you thinking of harming yourself?
- B. It will take time, but you will feel the same.
- C. Your friends will understand when you explain it was not your fault.
- D. You will be able to find meaning in this experience as time goes on.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.
A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment, saying only, 'I will not eat until I lose enough weight to look thin.' Select the best initial nursing diagnosis.
- A. Anxiety related to fear of weight gain.
- B. Disturbed body image related to weight loss.
- C. Ineffective coping related to lack of conflict resolution skills.
- D. None of the above.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): None of the above is the best initial nursing diagnosis because the patient's symptoms suggest a severe medical condition rather than psychological issues. The yellow skin, cold extremities, low heart rate, extreme low weight, and refusal to eat indicate severe malnutrition and possible organ failure. Therefore, the priority is to address the patient's immediate medical needs, such as restoring electrolyte balance and preventing further complications. Psychological assessments and diagnoses can follow once the patient's physical health is stabilized.
Summary of Other Choices:
A: Anxiety related to fear of weight gain - This choice focuses on psychological factors, but the patient's symptoms indicate severe physical malnutrition rather than anxiety.
B: Disturbed body image related to weight loss - While body image issues may be present, the patient's critical medical condition takes precedence over psychological concerns.
C: Ineffective coping related to lack of conflict resolution skills - This choice does not address the urgency of the patient's physical symptoms and is not the most