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When coping with a patient's inappropriate expression of anger, a psychiatric-mental health nurse's initial action is to identify the:
- A. appropriate limit-setting techniques
- B. nurse's own response to the anger
- C. patient's specific defense mechanisms
- D. systems theory for effecting change
Correct Answer: B
Rationale: Understanding the nurse's own emotional response ensures objectivity and effective management of the patient's anger.
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A drug causes muscarinic receptor blockade. The nurse will assess the patient for
- A. Dry mouth.
- B. Gynecomastia.
- C. Pseudoparkinsonism.
- D. Orthostatic hypotension.
Correct Answer: A
Rationale: The correct answer is A: Dry mouth. Muscarinic receptor blockade inhibits the action of acetylcholine, leading to decreased salivary gland secretion and causing dry mouth. Gynecomastia (B) is associated with antiandrogen medications. Pseudoparkinsonism (C) is a side effect of antipsychotic medications that block dopamine receptors. Orthostatic hypotension (D) is a side effect of alpha-1 adrenergic receptor blockade.
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.
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse assesses the client's stage of Alzheimer's disease as stage:
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B (stage 2) because the client is exhibiting symptoms of moderate Alzheimer's disease, such as paranoia and delusions. In stage 2, cognitive decline becomes more noticeable, leading to memory loss, confusion, and behavioral changes. The client's accusations and false beliefs indicate a decline in reality orientation, which is characteristic of stage 2. Choices A, C, and D are incorrect because stage 1 is characterized by mild cognitive decline, stage 3 by severe cognitive decline, and stage 4 by very severe cognitive decline.
A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest?
- A. Determine the nature and extent of the coach's sexual disorder.
- B. Assess the coach's potential for suicide or other self-harm.
- C. Assess the coach's self-perception of problem and needs.
- D. Determine whether other children were harmed.
Correct Answer: B
Rationale: The correct answer is B: Assess the coach's potential for suicide or other self-harm. This is the priority nursing action because the coach may be experiencing intense emotional distress and may be at risk for harming themselves. By assessing for suicidal ideation or self-harm, the nurse can ensure the coach's safety and provide appropriate interventions if needed.
Choice A is incorrect because determining the nature and extent of the coach's sexual disorder is not the priority at this moment. Choice C is also incorrect as assessing the coach's self-perception of the problem and needs can be addressed after ensuring their immediate safety. Choice D is incorrect as determining whether other children were harmed is important but not the priority immediately following the coach's arrest.
Explain four (4) the behavioral features of Anorexia Nervosa
- A. Restricting food intake
- B. Excessive exercise
- C. Body image distortion
- D. Fear of weight gain
Correct Answer: A
Rationale: These behaviors reflect the core features of anorexia: restriction, overactivity, distorted perception, and weight obsession.