What is the primary goal for a nurse treating a patient with anorexia nervosa?
- A. To help the patient achieve optimal body weight quickly.
- B. To restore the patient's nutritional balance and weight.
- C. To involve the patient in daily exercise routines to improve physical health.
- D. To encourage the patient to undergo intensive psychotherapy.
Correct Answer: B
Rationale: The primary goal for a nurse treating a patient with anorexia nervosa is to restore the patient's nutritional balance and weight. This is because individuals with anorexia nervosa often have severe malnutrition and weight loss, which can lead to serious health complications. By focusing on restoring nutritional balance and weight, the nurse can help improve the patient's physical health and overall well-being. Encouraging the patient to achieve optimal body weight quickly (choice A) may not be realistic or safe, as rapid weight gain can have negative consequences. Involving the patient in daily exercise routines (choice C) may exacerbate the patient's compulsive behaviors around food and exercise. Encouraging the patient to undergo intensive psychotherapy (choice D) is important, but it is not the primary goal in the initial treatment of anorexia nervosa.
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A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.
For those family members who desire to care at home for loved ones who have been given a diagnosis of Alzheimer's disease, it is important for the nurse to ensure that the family is aware of which caregiver skills and responsibilities will be necessary. What is one of the responsibilities of the caregiver during the middle stage of the disease?
- A. Helping the loved one with memory and communication problems
- B. Providing a stable, routine environment
- C. Providing complete assistance with physical care
- D. Adapting to the changing personality and behavior of the loved one
Correct Answer: D
Rationale: The correct answer is D: Adapting to the changing personality and behavior of the loved one. During the middle stage of Alzheimer's disease, individuals may experience significant changes in personality and behavior. Caregivers need to adapt to these changes by being patient, understanding, and flexible. This responsibility is crucial for maintaining a positive and supportive relationship with the loved one.
A: Helping the loved one with memory and communication problems is important, but it is more relevant in the early stages of the disease when these issues are more prominent.
B: Providing a stable, routine environment is essential throughout all stages of Alzheimer's disease, not just the middle stage.
C: Providing complete assistance with physical care may become necessary in the later stages of the disease when the individual's physical abilities decline significantly.
The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. What components should the plan include? Select all that apply.
- A. A code word to signal children that it is time to leave.
- B. Phone numbers for the nearest shelter and crisis hotline.
- C. Telling the spouse that she has a plan and will leave.
- D. Collecting birth certificates and other essential documents.
Correct Answer: A
Rationale: The correct answer is A: A code word to signal children that it is time to leave. This is crucial for ensuring the safety of the victim and their children without alerting the abuser. Other choices like B, providing phone numbers for shelters, are important but may not always be feasible in an emergency. Choice C, informing the spouse about the plan, can escalate the situation. Choice D, collecting essential documents, is important but may not always be the immediate priority in a dangerous situation. Having a code word ensures a discreet and quick escape if needed.
A person who was raped comes to the hospital for treatment. The person abruptly decides to decline treatment and leave the facility. Before this person leaves, the nurse should:
- A. Say, "You may not leave until you're given prophylactic treatment for sexually transmitted diseases."Â
- B. Provide written information about physical and emotional reactions the person may experience.
- C. Explain the need and importance of HIV and pregnancy tests.
- D. Give verbal information about legal resources.
Correct Answer: B
Rationale: The correct answer is B because providing written information about physical and emotional reactions respects the individual's autonomy and empowers them to make informed decisions. It also ensures they have resources to understand and cope with potential consequences. Choice A violates the individual's right to refuse treatment. Choice C focuses on specific tests without addressing the person's immediate concerns. Choice D, while important, is not as immediate or relevant as providing information on potential reactions.
A patient with anorexia nervosa is being treated with refeeding. Which complication should the nurse monitor for during this phase?
- A. Hyperkalemia and hyperglycemia.
- B. Hypophosphatemia and cardiac arrhythmias.
- C. Increased appetite and food cravings.
- D. Dehydration and hypotension.
Correct Answer: B
Rationale: The correct answer is B: Hypophosphatemia and cardiac arrhythmias. During refeeding in anorexia nervosa, there is a risk of rapid shifts in electrolytes, particularly phosphorus, leading to hypophosphatemia which can cause cardiac arrhythmias. This is a critical complication that the nurse should monitor for. Hyperkalemia and hyperglycemia (choice A) are less common in refeeding syndrome. Increased appetite and food cravings (choice C) are expected outcomes of refeeding, not complications. Dehydration and hypotension (choice D) are potential issues but are not specific to refeeding in anorexia nervosa.