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What is the priority nursing intervention for a patient with bulimia nervosa who is engaging in purging behaviors?
- A. Monitor electrolyte levels and cardiac function.
- B. Encourage self-monitoring of food intake.
- C. Provide emotional support and promote body image acceptance.
- D. Focus on encouraging weight loss through diet control.
Correct Answer: A
Rationale: The correct answer is A. The priority nursing intervention for a patient with bulimia nervosa engaging in purging behaviors is to monitor electrolyte levels and cardiac function. This is crucial due to the potential electrolyte imbalances and cardiac complications resulting from purging behaviors. Monitoring these parameters helps prevent life-threatening conditions such as hypokalemia and arrhythmias.
Option B is incorrect as self-monitoring of food intake may not address the immediate health risks associated with purging behaviors. Option C is also incorrect as emotional support and body image acceptance are important but not the immediate priority in this case. Option D is incorrect as focusing on weight loss through diet control can exacerbate the patient's eating disorder behaviors and does not address the urgent medical concerns associated with purging.
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Which statement by a patient with anorexia nervosa indicates a need for further education?
- A. I understand that my weight loss is dangerous, and I want to regain weight.
- B. I feel good about my body and don't need to gain weight.
- C. I am willing to work with my healthcare team to restore my nutrition.
- D. I know I need to eat more to improve my health.
Correct Answer: B
Rationale: The correct answer is B because feeling good about their body and not recognizing the need to gain weight is a common symptom of anorexia nervosa. This statement indicates a lack of insight into the seriousness of their condition and the necessity to restore a healthy weight. The other choices (A, C, D) demonstrate an understanding of the importance of weight gain, collaboration with healthcare professionals, and the need for increased food intake to improve health, indicating a willingness to engage in treatment and recovery.
An individual accompanied by a sibling was brought by ambulance to the emergency room with suspected impaired cognitive function. The patient's aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first consider:
- A. applying four-point restraints.
- B. using a calm tone to orient the patient.
- C. leaving the patient alone with the sibling.
- D. calling for security guards to hold the patient down.
Correct Answer: B
Rationale: The correct answer is B: using a calm tone to orient the patient. This is the most appropriate initial intervention because it aims to address the patient's aggressive behavior by providing reassurance and attempting to reorient them to their surroundings. Using a calm tone can help de-escalate the situation and improve communication with the patient. Applying four-point restraints (choice A) should be avoided as it is a restrictive measure that should only be used as a last resort to ensure patient safety. Leaving the patient alone with the sibling (choice C) may exacerbate the safety issue, as the sibling may not be equipped to manage the situation. Calling for security guards to hold the patient down (choice D) is a forceful approach that should be avoided until all other options have been exhausted.
A victim of rape says, "My family is not very supportive."Â Which belief contributes to a negative family response?
- A. No one asks to be raped.
- B. Rape is an act of aggression.
- C. Rape should not be discussed.
- D. Anyone is a potential rape victim.
Correct Answer: C
Rationale: The correct answer is C: Rape should not be discussed. This belief contributes to a negative family response because it promotes silence and stigma around the topic of rape, leading to lack of support and understanding for the victim. By not discussing rape, the victim may feel isolated, ashamed, and unable to seek help or share their experience. Choices A and B are incorrect as they acknowledge the victim's innocence and the violent nature of rape. Choice D is incorrect as it recognizes the reality that anyone can be a victim, but it does not directly address the issue of discussing rape within the family.
Which of these assessment findings would indicate that a rape victim is exhibiting behavior typically seen in the acute stage of sexual assault?
- A. Patient is very demanding and controlling in manner when dealing with staff.
- B. Patient appears to be confused, restless, and fearful when left alone.
- C. Patient uses profanity to describe the events surrounding the attack.
- D. Patient experiences a panic attack on the anniversary of the attack.
Correct Answer: B
Rationale: The correct answer is B because exhibiting confusion, restlessness, and fear when left alone aligns with the acute stage of sexual assault trauma. During this stage, victims often experience shock, disbelief, and heightened anxiety. This behavior reflects immediate emotional distress and trauma response. Choice A indicates characteristics of control and demanding behavior, which are not typically seen in the acute stage. Choice C suggests using profanity, which may vary based on individual coping mechanisms. Choice D indicates a specific trigger response on the anniversary, suggesting a later stage of processing trauma, not the acute phase.
It is a secondary dementia indicated by loss of recent memory and disorientation to time and place.
- A. Alzheimer's disease.
- B. Vascular dementia.
- C. Lewy body dementia.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Alzheimer's disease. Alzheimer's disease is a common type of dementia characterized by progressive cognitive decline, including loss of recent memory and disorientation to time and place. This is due to the accumulation of amyloid plaques and neurofibrillary tangles in the brain. Vascular dementia (B) is caused by reduced blood flow to the brain, leading to cognitive impairment. Lewy body dementia (C) is characterized by the presence of abnormal protein deposits called Lewy bodies in the brain. Choosing D (None of the above) would be incorrect as Alzheimer's disease specifically matches the description provided in the question.