Nokea
What is the primary nursing intervention for a patient with anorexia nervosa who is refusing to eat?
- A. Offer rewards for eating meals.
- B. Provide firm encouragement and offer small, frequent meals.
- C. Enforce strict diet control and limit food choices.
- D. Allow the patient to skip meals if they do not feel hungry.
Correct Answer: B
Rationale: The correct answer is B because providing firm encouragement and offering small, frequent meals is a supportive approach to help the patient with anorexia nervosa overcome their fear of eating. It helps in gradually reintroducing food, building trust, and establishing a healthier eating pattern. Offering rewards (A) may reinforce unhealthy eating behaviors. Enforcing strict diet control (C) can exacerbate control issues and worsen the patient's condition. Allowing the patient to skip meals (D) can perpetuate malnutrition and reinforce avoidance behaviors.
You may also like to solve these questions
A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse's first action should be to:
- A. Take the client's vital signs
- B. Restrain the client to prevent injury
- C. Obtain a pm order for a psychotropic medication
- D. Ask the client for information about his medications
Correct Answer: A
Rationale: The correct answer is A: Take the client's vital signs. The first step in assessing any client in the emergency department is to ensure their physiological stability. Vital signs provide essential information about the client's current physical condition, such as heart rate, blood pressure, respiratory rate, and temperature. In this case, the client's alternating states of hyperalertness and difficulty in arousal, disorientation, confusion, agitation, memory impairment, delusions, and misinterpretations of surroundings indicate a potential medical emergency. Therefore, taking the client's vital signs is crucial to determine if there are any immediate life-threatening conditions that need to be addressed promptly.
Summary of other choices:
B: Restrain the client to prevent injury - Restraint should only be used as a last resort for safety concerns and after assessing the client's physical condition.
C: Obtain a PRN order for a psychotropic medication - Administering psychotropic medication should not be the first action without assessing the client's physical condition and
Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a client about self-management?
- A. Teach material in small segments
- B. Use only verbal instruction
- C. Plan the teaching for a time when client is stimulated and busy
- D. Offer opportunities for making a large number of choices
Correct Answer: A
Rationale: The correct answer is A because teaching material in small segments is effective for individuals with cognitive disturbances like schizophrenia, as it helps improve comprehension and retention. Breaking down information into manageable parts reduces cognitive overload and enhances learning. Choice B is incorrect as relying solely on verbal instruction may be challenging for individuals with cognitive deficits. Choice C is incorrect because a stimulated and busy environment may hinder learning for someone with schizophrenia due to difficulty focusing. Choice D is incorrect as offering too many choices can be overwhelming and confusing, especially for those with cognitive disturbances.
A patient with many positive symptoms of schizophrenia, whose behavior is disorganized and who is highly anxious, tells the nurse in the psychiatric emergency department, 'You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun.' The patient, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend:
- A. admission to an unlocked residential crisis unit.
- B. inpatient hospitalization on a locked unit.
- C. attending a day treatment program for 4 weeks.
- D. admission to a partial hospital program.
Correct Answer: B
Rationale: The correct answer is B: inpatient hospitalization on a locked unit. This option is the most appropriate given the patient's presentation. The patient is experiencing severe positive symptoms of schizophrenia, such as delusions and disorganized behavior, posing a risk to himself and others by expressing intent to obtain a gun. Additionally, the patient is neglecting basic needs, indicating a need for close monitoring and intervention. Inpatient hospitalization on a locked unit provides a structured and secure environment for intensive treatment, ensuring safety and stabilization.
Incorrect choices:
A: Admission to an unlocked residential crisis unit may not provide the level of monitoring and security needed for a patient with active psychotic symptoms and self-harm potential.
C: Attending a day treatment program for 4 weeks does not address the acute safety concerns and level of impairment displayed by the patient.
D: Admission to a partial hospital program may not offer the round-the-clock supervision and immediate intervention required for someone at risk of harming themselves or others.
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.
A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa?
- A. I'm fat and ugly.
- B. What I think about myself is my business.
- C. I'm grossly underweight, but I cover it well.
- D. I'm a few pounds overweight, but I can live with it.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. The patient's history of significant weight loss and refusal to eat align with symptoms of anorexia nervosa.
2. Choice A reflects negative body image common in anorexia nervosa, as patients often perceive themselves as overweight and unattractive.
3. Choices B, C, and D do not acknowledge the patient's actual physical condition or the psychological aspect of anorexia nervosa.
4. Choice B avoids the question and lacks insight into the patient's distorted body image.
5. Choice C acknowledges being underweight but does not address the negative self-perception associated with anorexia nervosa.
6. Choice D acknowledges being overweight, which contradicts the patient's actual weight loss history and is inconsistent with anorexia nervosa's symptoms.