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What is the primary nursing concern for a patient with anorexia nervosa during the early stages of treatment?
- A. Ensuring rapid weight gain to restore health.
- B. Addressing the patient's psychological issues related to body image.
- C. Maintaining nutritional intake to prevent further weight loss.
- D. Promoting self-esteem and body image satisfaction.
Correct Answer: C
Rationale: The primary nursing concern for a patient with anorexia nervosa in the early stages of treatment is maintaining nutritional intake to prevent further weight loss. This is crucial as malnutrition can lead to serious health complications. Ensuring adequate nutrition supports physical health and provides a foundation for addressing psychological issues in later stages of treatment. Rapid weight gain (A) can be harmful and lead to refeeding syndrome. Addressing psychological issues (B) and promoting self-esteem (D) are important but secondary concerns once nutritional stability is achieved.
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A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to my husband, since he continues to abuse me.' The nurse is aware that the final decision to leave a batterer:
- A. Often occurs after the victim suffers a serious injury
- B. Is usually a gradual process that occurs over time
- C. Is more likely if the client has approval from the church
- D. Is made with the batterer's permission
Correct Answer: B
Rationale: The correct answer is B: Is usually a gradual process that occurs over time.
Rationale:
1. Leaving an abusive partner is a complex and difficult decision that often requires careful planning and support.
2. Victims may face various barriers such as financial dependence, emotional attachment, and fear of further violence.
3. It is rare for victims to abruptly leave without considering their safety and well-being.
4. The statement 'I probably should not keep going back' indicates a gradual realization and contemplation of leaving.
Summary:
A: The decision to leave is not solely based on serious injury; victims may leave before any significant harm occurs.
C: Approval from the church may influence the victim's decision but is not a determining factor.
D: Leaving an abusive partner should not require the batterer's permission; it is a personal choice made by the victim.
A nurse plans a staff education program for employees of a senior living community. Which topic has priority?
- A. Late-onset schizophrenia
- B. Depression and suicide
- C. Dementia
- D. Delirium
Correct Answer: B
Rationale: Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide (B). Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease morbidity and mortality. The other conditions (A, C, D) have a lower prevalence.
Police bring a patient to the mental health unit. The patient was directing traffic and shouting rhymes on a busy city street. The patient's spouse reports that the patient has not slept or eaten for 3 days. Which assessment findings have priority concern for this patient's plan of care?
- A. Pressured speech and grandiosity
- B. Hyperactivity; not eating and sleeping
- C. Poor concentration and decision making
- D. Insulting
Correct Answer: B
Rationale: The correct answer is B. Hyperactivity, not eating, and not sleeping are priority concerns as they indicate potential mania or hypomania, which can be dangerous and require immediate intervention. Not eating and sleeping for days can lead to physical and mental health complications. Pressured speech and grandiosity (Choice A) are symptoms of mania but not as urgent as lack of eating and sleeping. Poor concentration and decision making (Choice C) are also symptoms of mania, but not as immediately concerning as the lack of eating and sleeping. Insulting behavior (Choice D) is not a priority concern for immediate intervention in this scenario.
A worker is characterized by her co-workers as 'painfully shy' and lacking in self-confidence. Her co-workers say she stays in her cubicle all day, never coming out for breaks or lunch. One day after falling on the ice in the parking lot, she goes to the nurse's office, where she apologizes for falling and mentions that she hopes the company will not fire her for being so clumsy. With which diagnosis is this presentation most consistent?
- A. Avoidant
- B. Dependent
- C. Histrionic
- D. Paranoid
Correct Answer: A
Rationale: The correct answer is A: Avoidant. This diagnosis is consistent because the worker exhibits characteristics of extreme shyness, lack of self-confidence, social avoidance, and fear of rejection or criticism. By apologizing excessively for a simple accident and expressing worry about being fired for it, the worker's behavior aligns with the avoidance of social situations and excessive concern about negative evaluation typical of Avoidant Personality Disorder.
Choice B: Dependent, does not fit as the worker is not displaying excessive need for others to take responsibility for major areas of her life.
Choice C: Histrionic, is not a match as this disorder is characterized by attention-seeking behavior, which is not evident in the worker's presentation.
Choice D: Paranoid, is not the correct diagnosis as the worker does not display distrust or suspiciousness towards others.
A nurse is caring for a patient with bulimia nervosa. The nurse should monitor for which of the following complications?
- A. Nutritional deficiency and dehydration.
- B. Respiratory failure and aspiration pneumonia.
- C. Peripheral edema and hyperkalemia.
- D. Mental confusion and decreased blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Nutritional deficiency and dehydration. In bulimia nervosa, recurrent episodes of binge eating followed by purging can lead to electrolyte imbalances, dehydration, and malnutrition. Monitoring for nutritional deficiencies and dehydration is crucial in managing patients with bulimia nervosa.
Explanation for why other choices are incorrect:
B: Respiratory failure and aspiration pneumonia - Although purging behaviors can increase the risk of aspiration pneumonia, it is not as common as nutritional deficiencies and dehydration in patients with bulimia nervosa.
C: Peripheral edema and hyperkalemia - These complications are not typically associated with bulimia nervosa.
D: Mental confusion and decreased blood pressure - While electrolyte imbalances can lead to mental confusion, these specific complications are not as common as nutritional deficiencies and dehydration in patients with bulimia nervosa.