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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 student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help from the university health clinic. During the initial interview, what priority issue should the nurse address?
- A. Losses
- B. Sleep patterns
- C. School activities
- D. Menstrual flow
Correct Answer: A
Rationale: The correct answer is A: Losses. The priority issue the nurse should address is the student's recent breakup and difficulty making friends, which are significant losses impacting her emotional well-being. By addressing these losses, the nurse can help the student process her emotions and develop coping strategies.
B: Sleep patterns may be affected by the student's emotional distress, but it is a secondary concern compared to addressing the underlying losses.
C: School activities are important, but the root cause of the student's decline in schoolwork is likely related to her emotional state following the breakup.
D: Menstrual flow is not the priority issue at this time as it is not directly related to the student's emotional struggles and academic decline.
After a rape victim visited a rape crisis counselor weekly for 8 weeks, which finding best demonstrates that reorganization was successful?
- A. Absence of signs or symptoms of posttraumatic stress disorder
- B. Presence of mild somatic reactions
- C. Moderate doubts about self-worth
- D. Occasional episodic nightmares
Correct Answer: A
Rationale: The correct answer is A because the absence of signs or symptoms of posttraumatic stress disorder indicates successful reorganization after therapy. This demonstrates that the victim has effectively processed and coped with the trauma. Choice B indicates lingering somatic reactions, C suggests ongoing self-esteem issues, and D implies unresolved trauma manifesting in nightmares, all of which do not reflect successful reorganization.
A Hispanic woman comes to the mental health center at the urging of her adult children. The patient has lost 5 pounds since her husband's death 6 months ago and says, "My husband comes to visit me in the night but I cannot understand what he says." How should the nurse analyze this situation? The patient is:
- A. Experiencing auditory and visual hallucinations.
- B. At high risk for imbalanced nutrition.
- C. Grieving the husband's death.
- D. Denying the husband's death.
Correct Answer: C
Rationale: The correct answer is C: Grieving the husband's death. The patient's statement about her deceased husband visiting her in the night and her weight loss following his death indicate a strong possibility of experiencing grief. This is a common manifestation of bereavement, where individuals may have difficulty accepting the reality of the loss and experience hallucinations or illusions involving the deceased. The patient's symptoms are more aligned with the normal process of grieving rather than psychosis. Choices A and B are incorrect because the patient's experiences are likely related to grief rather than auditory and visual hallucinations or imbalanced nutrition. Choice D is incorrect as the patient's statements suggest she is aware of her husband's death but is struggling to cope with it emotionally.
Suicidal tendency is most commonly seen with
- A. Schizophrenia
- B. Obsessive Disorders
- C. Mania
- D. Depression
Correct Answer: D
Rationale: Depression is the most common mental disorder associated with suicidal tendencies due to persistent feelings of hopelessness and despair.
Asking the husband to leave is likely to increase the client's anxiety and alter test results. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.
- A. Asking the husband to leave is likely to increase the client's anxiety and alter test results because the presence of a loved one can provide comfort and support during a potentially stressful situation.
- B. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results because the client is in a setting where they feel safe and secure, which can help reduce anxiety and promote accurate test outcomes.
- C. Both A and B.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C because both statements A and B provide valid reasons supported by psychological principles. Statement A is correct as the presence of a loved one can indeed provide comfort and support, reducing anxiety and potentially improving test outcomes. Statement B is also accurate as testing in familiar surroundings can help the client feel safe and secure, leading to more reliable results. Therefore, combining these two factors - the presence of a loved one and testing in a comfortable environment - would likely yield the most reliable results by addressing both emotional and environmental factors impacting the client's anxiety levels during the test.