Which expectation should be considered most critical prior to discharging a client with anorexia nervosa from the hospital?
- A. Attainment of minimum normal weight.
- B. Resumption of normal menstrual cycle.
- C. Knowledge of caloric and nutritional value of foods required for a balanced diet.
- D. Reduction of periods of active exercise to three times daily.
Correct Answer: A
Rationale: Rationale: A critical expectation before discharging a client with anorexia nervosa is the attainment of minimum normal weight. This is crucial for the client's physical health and to prevent complications like organ damage. Resuming a normal menstrual cycle (B) is important but not as critical as restoring weight. Knowing about nutrition (C) is valuable but not as urgent as weight gain. Reducing exercise (D) may be necessary, but weight restoration takes precedence for overall health.
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The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior living facility. The client thinks he is in the army and that it is 1945. The nurse should:
- A. Reorient the client to the current time and place.
- B. Notify the client's family of the confusion.
- C. Document the client's confusion and disorientation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Reorient the client to the current time and place. The nurse should reorient the client to prevent distress and promote safety. This approach helps the client feel more secure and may reduce confusion. Choice B is incorrect because the nurse should address the client's needs first. Choice C is not enough on its own as the nurse needs to actively assist the client. Choice D is incorrect as action is needed in this situation to support the client.
Which nursing diagnosis is a priority for both a patient with depression and one with acute mania?
- A. Deficient diversional activity
- B. Disturbed sleep pattern
- C. Fluid volume excess
- D. Defensive coping
Correct Answer: B
Rationale: The correct answer is B: Disturbed sleep pattern. Both depression and acute mania can disrupt sleep, leading to negative impacts on overall health. Sleep disturbances can exacerbate symptoms of both conditions and hinder recovery. Addressing sleep patterns is crucial in managing symptoms and improving outcomes for patients with depression and acute mania.
A: Deficient diversional activity is more relevant to depression than acute mania, as patients with mania often engage in excessive activities.
C: Fluid volume excess is not typically associated with depression or acute mania.
D: Defensive coping may be relevant to both conditions but is not a priority compared to addressing sleep patterns for patient safety and symptom management.
A core feature of all abnormal behavior is that it is
- A. culturally absolute
- B. learned
- C. maladaptive
- D. dependent on age
Correct Answer: C
Rationale: Maladaptive behavior, impairing function or causing distress, is a universal hallmark of abnormality.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. The patients level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.
A patient with antisocial personality disorder tells Nurse A, 'You're a much better nurse than Nurse B said you were.' The patient tells Nurse B, 'Nurse A's upset with you for some reason.' To Nurse C the patient states, 'You'd like to think you're perfect, but I've seen three of your mistakes this morning.' These comments can best be assessed as:
- A. seductive.
- B. detached.
- C. guilt producing.
- D. manipulative.
Correct Answer: D
Rationale: The correct answer is D: manipulative. The patient's behavior demonstrates manipulation by attempting to create discord and control the relationships between the nurses. The patient uses different tactics to manipulate each nurse's emotions and perceptions for personal gain. Seductive (choice A) implies enticing or charming behavior, which is not evident in the scenario. Detached (choice B) suggests a lack of emotional connection, which is not the focus here. Guilt producing (choice C) involves inducing guilt, which the patient is not directly doing in this situation. Manipulative (choice D) best captures the patient's intent to influence others through deceptive and controlling tactics.