Nokea
What is the primary concern when caring for a patient with bulimia nervosa who has been purging regularly?
- A. Managing the patient's weight gain.
- B. Assessing for complications related to electrolyte imbalances.
- C. Encouraging exercise to offset caloric intake.
- D. Promoting food restriction to control binge eating.
Correct Answer: B
Rationale: The correct answer is B: Assessing for complications related to electrolyte imbalances. This is the primary concern when caring for a patient with bulimia nervosa who has been purging regularly because purging behaviors, such as self-induced vomiting or laxative abuse, can lead to severe electrolyte imbalances which can be life-threatening. Electrolyte imbalances can result in cardiac arrhythmias, muscle weakness, and other serious complications. Managing weight gain (A), encouraging exercise (C), and promoting food restriction (D) are not appropriate approaches as they can exacerbate the patient's unhealthy behaviors and may worsen their condition. It is crucial to prioritize assessing and addressing electrolyte imbalances to ensure the patient's safety and well-being.
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An outpatient diagnosed with schizophrenia tells the nurse, I am here to save the world. I threw away the pills because they make God go away. The nurse identifies the patients reason for medication nonadherence as:
- A. poor alliance with clinicians.
- B. inadequate discharge planning.
- C. dislike of medication side effects.
- D. lack of insight associated with the illness.
Correct Answer: D
Rationale: The patient's belief in an exalted role and rejection of medication due to hallucinations (God's voice) reflect lack of insight (D) into their illness, the primary reason for nonadherence here.
A client in her early teens who is being treated for irritable bowel syndrome has just disclosed that she has been feeling anxious. For what other condition should the nurse assess this client?
- A. Anxiety.
- B. Depression.
- C. Eating disorder.
- D. None of the above.
Correct Answer: A
Rationale: Step 1: The client disclosed feeling anxious.
Step 2: Anxiety is a common comorbidity with irritable bowel syndrome.
Step 3: Assessing for anxiety allows for holistic treatment.
Step 4: Anxiety can impact the client's physical health.
Step 5: Therefore, assessing for anxiety is crucial.
Summary:
B: Depression - While depression is important, the client disclosed anxiety.
C: Eating disorder - Not directly related to the client's disclosure.
D: None of the above - Incorrect, as assessing for anxiety is necessary.
A nurse is working with a perpetrator of family violence who has a long history of violent rages when frustrated, with periods of remorse after each outburst. The nurse is most likely to establish the nursing diagnosis of:
- A. Risk for injury related to victim reprisal.
- B. Risk for other-directed violence related to stress.
- C. Ineffective coping related to poor anger management.
- D. Caregiver role strain related to feelings of being overwhelmed.
Correct Answer: C
Rationale: The correct answer is C: Ineffective coping related to poor anger management. This nursing diagnosis is appropriate because it addresses the perpetrator's inability to manage their anger effectively, leading to violent outbursts. The perpetrator's history of violent rages and subsequent remorse suggest a pattern of maladaptive coping mechanisms. This diagnosis focuses on the underlying issue of poor anger management, which is essential to address in order to prevent future acts of violence.
Choices A, B, and D are incorrect:
A: Risk for injury related to victim reprisal - This choice places the focus on potential harm to the victim as a result of retaliation, which is not the primary issue in this scenario.
B: Risk for other-directed violence related to stress - While stress may contribute to the perpetrator's behavior, the primary issue lies in their poor anger management rather than just stress.
D: Caregiver role strain related to feelings of being overwhelmed - This choice is not appropriate as it does not address the core issue of poor
The nurse performs a functional assessment of a client upon admission to a home health agency. 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. None of the above.
Correct Answer: B
Rationale: Rationale:
1. Functional assessment evaluates client's ability to perform ADLs.
2. Assessing ADLs helps determine client's independence level.
3. Independence in ADLs impacts care planning and interventions.
4. Level of consciousness (A) is related to neurological status, not functional ability.
5. Reasoning, judgment (C) are cognitive functions, not directly related to ADLs.
6. "None of the above" (D) excludes the correct purpose of functional assessment.
A useful strategy for helping a patient with schizophrenia manage a potential relapse is to:
- A. have the patient attend group therapy.
- B. advise the patient to continue taking medication daily.
- C. teach the patient and family about behaviors that indicate impending relapse.
- D. schedule appointments for blood tests to determine serum medication levels.
Correct Answer: C
Rationale: The correct answer is C because teaching the patient and family about behaviors indicating an impending relapse helps in early detection and intervention. This empowers them to recognize warning signs like changes in behavior or mood, allowing for prompt action.
Choice A (group therapy) may be beneficial for support but does not directly address relapse prevention. Choice B (medication adherence) is crucial but not specific to relapse management. Choice D (blood tests) is important for monitoring medication levels but does not focus on recognizing relapse indicators.