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Which finding is most indicative of refeeding syndrome in a patient with anorexia nervosa?
- A. Increased energy and mental clarity after eating.
- B. Electrolyte imbalances, particularly hypophosphatemia.
- C. A sudden increase in appetite and food cravings.
- D. Rapid weight gain and hypertension.
Correct Answer: B
Rationale: The correct answer is B because refeeding syndrome is characterized by electrolyte imbalances, especially hypophosphatemia, due to rapid reintroduction of nutrition. This can lead to serious complications like cardiac arrhythmias and respiratory failure. Increased energy and mental clarity (A) are not specific to refeeding syndrome. A sudden increase in appetite and food cravings (C) may occur but are not indicative of refeeding syndrome. Rapid weight gain and hypertension (D) are not typically seen in refeeding syndrome.
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What environmental conditions should the nurse arrange for a patient with delirium and altered perceptions of their environment?
- A. Provide a quiet, well-lit room without glare or shadows.
- B. Have the patient sit by the nurse's desk while awake.
- C. Reduce room lighting to minimize overstimulation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because a quiet, well-lit room without glare or shadows helps reduce environmental stimuli that can exacerbate delirium and altered perceptions. This environment promotes calmness and clarity for the patient. Choice B is incorrect as it may increase distractions and stimuli. Choice C may lead to inadequate lighting that can worsen confusion. Choice D is incorrect as environmental modifications are crucial for managing delirium.
A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority nursing diagnosis for this client is:
- A. Anxiety
- B. Risk for self-mutilation
- C. Risk for other-directed violence
- D. Ineffective coping
Correct Answer: B
Rationale: The correct answer is B: Risk for self-mutilation. This is the priority nursing diagnosis because the client is displaying behaviors such as self-injury due to difficulty tolerating angry feelings. Self-mutilation poses an immediate risk to the client's safety and requires immediate intervention. The other choices are incorrect because anxiety (A) is a common symptom of borderline personality disorder but not the priority in this case. Risk for other-directed violence (C) is not indicated as the client is primarily harming themselves. Ineffective coping (D) is a broad diagnosis that does not address the immediate risk of self-mutilation.
When a patient with a personality disorder uses manipulation as a way of getting needs met, the staff agree to use limit setting as an intervention. How does limit setting work to reduce manipulation?
- A. Limit setting indulges the patient's desire for attention from staff.
- B. It gives the patient a different concern on which to focus his anger.
- C. External controls provide security while internal controls are developing.
- D. When staff limit the patient's behavior, he is no longer anxious about it.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. External controls, like limit setting, provide structure and predictability for the patient.
2. This security allows the patient to gradually develop internal controls to manage their behavior.
3. By relying on external limits, the patient's need for manipulation decreases over time.
4. This approach fosters growth and autonomy in the patient, reducing the reliance on manipulative behaviors.
Summary:
A: Incorrect. Limit setting does not indulge attention-seeking behaviors; it establishes boundaries.
B: Incorrect. Limit setting does not redirect anger; it focuses on promoting internal control.
D: Incorrect. Limit setting does not solely address anxiety; it aims to foster self-regulation.
A child, age 5, was admitted to the children's unit, having been sexually abused by an acquaintance of her family. The child refuses to talk and participate in unit activities, choosing to stay in her room with her stuffed animals. Which therapeutic intervention will best help the child release pent-up feelings about the abuse?
- A. Individual communication with the nurse
- B. Play therapy
- C. Family therapy
- D. Role-play with other children on the unit
Correct Answer: B
Rationale: The correct answer is B: Play therapy. Play therapy is the most suitable therapeutic intervention for a child in this scenario because it allows the child to express their feelings and experiences through play, which is a natural form of communication for children. Through play therapy, the child can act out their experiences using toys and create a safe space to process their emotions without having to verbally communicate. It helps the child release pent-up feelings and trauma in a non-threatening environment.
Summary of other choices:
A: Individual communication with the nurse may not be as effective as play therapy in this case as the child is not yet comfortable verbalizing their feelings.
C: Family therapy may not be appropriate at this stage as the child is not ready to engage with family members about the abuse.
D: Role-play with other children on the unit may not be beneficial as it can potentially trigger more anxiety and discomfort for the abused child.
A person who has an extreme lack of self-confidence and who allows others to run his or her life is said to have a(n) personality
- A. dependent
- B. narcissistic
- C. paranoid
- D. antisocial
Correct Answer: A
Rationale: Dependent personality disorder involves excessive reliance on others and low self-confidence, matching this description.