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Which nursing diagnosis is more relevant for a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges?
- A. Powerlessness
- B. Ineffective coping
- C. Disturbed body image
- D. Imbalanced nutrition: less than body requirements
Correct Answer: D
Rationale: The correct answer is D, Imbalanced nutrition: less than body requirements. For a patient with anorexia nervosa who restricts intake and is 20% below normal weight, this diagnosis is more relevant as it directly addresses the issue of inadequate food intake leading to weight loss. Powerlessness (A) may not be as directly related to the physical consequences of anorexia. Ineffective coping (B) and Disturbed body image (C) are more commonly associated with bulimia nervosa and do not address the primary concern of malnutrition in this case.
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A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, 'Without the red teddies, I am not interested in sex.' The nurse can assess this as consistent with
- A. exhibitionism.
- B. voyeurism.
- C. frotteurism.
- D. fetishism.
Correct Answer: D
Rationale: The correct answer is D: fetishism. Fetishism is a sexual disorder where a person is sexually aroused by an object or body part that is not typically considered sexual. In this scenario, the patient's arousal is dependent on his wife wearing a specific type of clothing (the red camisole-style nightgowns), indicating a fetishistic preference for that particular item. This is different from exhibitionism (A), which involves exposing one's genitals to unsuspecting strangers; voyeurism (B), which involves observing unsuspecting individuals undressing or engaging in sexual activity; and frotteurism (C), which involves touching or rubbing against a non-consenting person for sexual arousal.
Persons who are excessively narcissistic, dependent, or antisocial are characterized as having
- A. somatoform disorders
- B. generalized anxiety
- C. conversion reactions
- D. personality disorders
Correct Answer: D
Rationale: Narcissistic, dependent, and antisocial traits define personality disorders, affecting interpersonal functioning.
An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate?
- A. Rofecoxib should not be taken with Ativan.
- B. Lorazepam interferes with the action of Inderal.
- C. The patient should not self-administer medication.
- D. Lorazepam and Ativan are the same drug, so the dose is excessive.
Correct Answer: D
Rationale: Lorazepam and Ativan are generic and trade names for the same drug (D), creating an accidental misuse situation with an excessive dose. The patient needs medication education and help with proper labeling; there is no evidence they cannot self-administer (C). Options A and B are not factually supported.
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. tardive dyskinesia"¦seek a change in the drug or its dosage
- C. waxy flexibility"¦continue treatment with antipsychotic drugs
- D. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
Correct Answer: A
Rationale: The correct answer is A: a dystonic reaction"¦administer PRN IM benztropine (Cogentin).
1. Dystonic reaction is characterized by involuntary muscle contractions, causing abnormal posture or movements.
2. The patient's symptoms of head rotation, jaw thrust, and severe anxiety align with dystonic reaction.
3. Benztropine is an anticholinergic medication used to treat dystonic reactions by blocking acetylcholine in the brain.
4. Administering benztropine promptly can alleviate the symptoms and prevent complications.
Other choices are incorrect:
B: Tardive dyskinesia develops with long-term antipsychotic use, presenting as repetitive, involuntary movements. Seeking a change in drug or dosage is not appropriate for acute dystonic reaction.
C: Waxy flexibility is a symptom of catatonia, not related to the patient's presentation of dystonic reaction.
D: Akathisia is restlessness and agitation often caused by
A catatonic patient admitted in a stuporous condition begins to demonstrate increased motor activity. During his assessment, the psychiatrist raises the patient's arm above his head and releases it. The patient maintains the position his arm was placed in, immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. What symptom is demonstrated by this assessment technique?
- A. Echopraxia
- B. Waxy flexibility
- C. Depersonalization
- D. Thought withdrawal
Correct Answer: B
Rationale: Waxy flexibility involves maintaining a posture imposed by another person, as seen in the patient's arm staying raised. This behavior is indicative of catatonia, a symptom of severe mental illness. Echopraxia involves mimicking movements of others, not maintaining a position. Depersonalization is a feeling of detachment from oneself, not related to physical movements. Thought withdrawal pertains to a symptom in schizophrenia where thoughts are removed by an external force, not related to physical posture.