Nokea
Which finding for a patient with an eating disorder most clearly indicates the need for hospitalization?
- A. Weight 15% below ideal weight
- B. Urine output less than 30 mL/hr
- C. Serum potassium 3.4 mEq/L
- D. Pulse rate 54 beats/min
Correct Answer: B
Rationale: The correct answer is B because urine output less than 30 mL/hr indicates severe dehydration and compromised kidney function, which can lead to organ failure. Hospitalization is necessary for immediate fluid resuscitation and monitoring. Option A is indicative of malnutrition but does not directly signify acute medical complications. Option C suggests hypokalemia, which can be managed on an outpatient basis. Option D, a low pulse rate, may be a sign of bradycardia but typically does not require immediate hospitalization unless accompanied by other severe symptoms.
You may also like to solve these questions
A client has just been diagnosed with mild Alzheimer's disease. A family member asks what medications are used for treatment. The nurse knows that which of the following medications are the ones most used for mild to moderate Alzheimer's disease? (Select all that apply.)
- A. Haloperidol (Haldol)
- B. Donepezil (Aricept)
- C. Rivastigmine (Exelon)
- D. Nonsteroidal antiinflammatory drugs
Correct Answer: B
Rationale: The correct answer is B: Donepezil (Aricept). Donepezil is a cholinesterase inhibitor commonly used to treat mild to moderate Alzheimer's disease by improving cognitive function. It is considered a first-line medication for Alzheimer's. Haloperidol (A) is an antipsychotic drug and not used for Alzheimer's treatment. Rivastigmine (C) is another cholinesterase inhibitor like donepezil, but it is more commonly used for moderate to severe Alzheimer's. Nonsteroidal anti-inflammatory drugs (D) are not typically used for Alzheimer's treatment. In summary, Donepezil is the preferred medication for mild to moderate Alzheimer's due to its effectiveness in improving cognitive symptoms.
A 14-year-old client on the eating disorders unit refuses to eat her meals and says to the nurse on the unit, 'You can't make me eat! There is nothing wrong with me.' The nurse will assess this as use of which defense mechanism?
- A. Repression.
- B. Rationalization.
- C. Sublimation.
- D. Denial.
Correct Answer: D
Rationale: The correct answer is D: Denial. Denial is a defense mechanism where an individual refuses to acknowledge reality to avoid discomfort. In this scenario, the client is denying the seriousness of their situation by refusing to eat and claiming there is nothing wrong. Repression (A) involves unconsciously blocking out unpleasant thoughts or feelings. Rationalization (B) is creating logical explanations to justify behavior. Sublimation (C) is redirecting negative impulses into positive behaviors. In this case, denial is the most fitting defense mechanism as the client is refusing to accept the reality of their eating disorder.
An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed. She admits to being very frightened. She is presently pacing and somewhat agitated in the examining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
- A. Interact with the client on an adult to child level.
- B. Place the client in a safe, nonstimulating environment.
- C. Ask client why she thinks someone would be trying to frighten her.
- D. Explain to the family that the client will be restrained for her own good.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a safe, nonstimulating environment. This is the most appropriate nursing intervention because the client is experiencing hallucinations and agitation, which could be due to the recent medication changes. Placing the client in a safe, calm environment can help reduce stimulation and provide a sense of security. This intervention addresses the client's immediate needs by ensuring her safety and promoting a sense of comfort.
Incorrect answers:
A: Interact with the client on an adult to child level - This is not appropriate as it does not address the client's current state of distress and could potentially worsen the situation.
C: Ask client why she thinks someone would be trying to frighten her - This is not the priority at this time, as the client is experiencing hallucinations and agitation that need to be managed first.
D: Explain to the family that the client will be restrained for her own good - Restraints should only be used as a last resort and should not be considered
The extreme reaction known as fugue refers to
- A. physical flight to escape conflict
- B. severe depression
- C. hallucinations
- D. obsessive behavior
Correct Answer: A
Rationale: Fugue is a dissociative state involving sudden travel or flight, often to escape stress.
A patient with borderline personality disorder has been making steady progress but one day gets a phone call from her boyfriend, who breaks off their relationship. Although she has not self-injured in over 2 months, she makes repeated lacerations on her forearm. Which statement about this and most maladaptive behaviors seen in personality disorders is most accurate?
- A. People with personality disorders rarely achieve lasting improvement.
- B. However dysfunctional, most behavior is the person's best effort to cope.
- C. People with personality disorders are at the mercy of others' actions.
- D. What appears to be improvement can be manipulation instead.
Correct Answer: B
Rationale: The correct answer is B: However dysfunctional, most behavior is the person's best effort to cope.
Rationale:
1. People with borderline personality disorder often struggle with intense emotions and unstable relationships.
2. Self-injury is a maladaptive coping mechanism used to manage overwhelming emotions or distress.
3. In this scenario, the patient resorts to self-injury as a coping strategy after the breakup triggers intense emotional pain.
4. Despite being maladaptive, the behavior serves as a coping mechanism to regulate emotions.
5. Understanding that maladaptive behaviors are often the individual's best attempt to cope helps in providing non-judgmental support and promoting healthier coping strategies.
Summary:
A: Incorrect. People with personality disorders can make progress with appropriate treatment and support.
C: Incorrect. While external factors may trigger behaviors, individuals with personality disorders have agency in their actions.
D: Incorrect. Improvement in behavior should not always be viewed as manipulation; it can indicate genuine progress in coping skills.