Nokea
Which nursing intervention has highest priority for a patient with bulimia nervosa?
- A. Assist the patient to identify triggers to binge eating.
- B. Provide remedial consequences for weight loss.
- C. Assess for signs of impulsive eating.
- D. Explore needs for health teaching.
Correct Answer: A
Rationale: The correct answer is A: Assist the patient to identify triggers to binge eating. The highest priority for a patient with bulimia nervosa is addressing the root cause of the behavior, which is often triggered by emotional or situational factors. By identifying triggers, the patient can learn to recognize and manage them effectively, ultimately reducing the frequency of binge eating episodes. This intervention focuses on addressing the underlying issue and promoting long-term recovery.
Summary:
B: Providing remedial consequences for weight loss is not the priority as the main concern is addressing the binge eating behavior.
C: Assessing for signs of impulsive eating is important, but identifying triggers takes precedence in addressing the behavior.
D: Exploring needs for health teaching may be relevant, but addressing triggers to binge eating is more immediate and crucial for managing bulimia nervosa.
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In the UK, the Special Education Needs & Disability Act of 2001 extended the rights of individuals with intellectual disabilities to be educated in mainstream schools. Schools are now required to draw up which of the following in order to facilitate the inclusion of pupils with intellectual disabilities and to make reasonable adjustments so that they are not disadvantaged?
- A. Inclusion strategies
- B. Facilitation strategies
- C. Accessibility strategies
- D. Availability strategies
Correct Answer: C
Rationale: Accessibility Strategies: Programmes extending rights of individuals with intellectual disabilities to be educated according to their needs in mainstream schools.
A patient with borderline personality disorder has been hospitalized several times after self-injurious behavior and suicide attempts. The patient has entered dialectical behavior therapy on an outpatient basis. During therapy, the advanced practice nurse has been counseling her regarding self-harm behavior management. Today the patient called the nurse and reported 'feeling empty and anxious' and wants to cut herself. Which response would best help in this situation?
- A. Arrange for an emergency admission to a crisis unit.
- B. Arrange for an emergency admission to an inpatient unit.
- C. Assist the patient to identify and choose a coping strategy.
- D. Advise the patient to take an anxiolytic, then go to sleep.
Correct Answer: C
Rationale: The correct response is C: Assist the patient to identify and choose a coping strategy. This choice is the best because it involves helping the patient develop healthy coping mechanisms to manage her distress. This empowers the patient to take control of her emotions and actions in a positive way. Emergency admissions (choices A and B) may not address the underlying issues and could potentially reinforce maladaptive behaviors. Advising medication (choice D) without addressing the emotional distress directly may not provide long-term solutions. In summary, choice C focuses on empowering the patient and addressing the root of the problem, making it the most appropriate response in this scenario.
During a manic episode, a patient is hyperactive, restless, and disorganized. The patient goes to the dining room and begins to throw food and dishes. Verbal intervention is ineffective. The patient's behavior poses a substantial risk of harm to others. Staff escorts the patient to the patient's room to dine alone. What is the rationale for this action?
- A. Prevent other patients from observing the behavior.
- B. Reduce environmental stimuli that negatively affect the patient.
- C. Protect the patient's biological integrity until medication takes effect.
- D. Reinforce limit setting
Correct Answer: B
Rationale: The correct answer is B: Reduce environmental stimuli that negatively affect the patient. This action helps reduce stimulation that may be exacerbating the manic episode, promoting a calmer environment for the patient. Removing the patient from the dining room minimizes triggers for further disruptive behavior. This approach prioritizes the patient's well-being by managing the environmental factors contributing to the escalation of symptoms.
A: Preventing other patients from observing the behavior does not directly address the patient's needs during the manic episode and does not actively help in managing the situation.
C: Protecting the patient's biological integrity until medication takes effect may be important, but in this scenario, the immediate focus is on addressing the environmental factors contributing to the behavior.
D: Reinforcing limit setting is important in managing behavior, but in this specific situation, reducing environmental stimuli is a more immediate and effective intervention.
The family of a client mentions to the nurse, 'The family therapist talked to us about enmeshment. We're not sure we understood what it meant.' The nurse should base a response on knowledge that an enmeshed family is a unit in which:
- A. individuality is encouraged.
- B. boundaries are poorly defined.
- C. conflict is effectively resolved.
- D. social acceptance is deemed unimportant.
Correct Answer: B
Rationale: The correct answer is B: boundaries are poorly defined. In an enmeshed family, boundaries between family members are blurred, leading to a lack of individual autonomy and independence. Enmeshment can result in difficulties in establishing personal identities and healthy relationships. Choices A, C, and D are incorrect because individuality is not encouraged, conflict is not effectively resolved, and social acceptance is not necessarily deemed unimportant in an enmeshed family dynamic.
A supervisor observes inconsistency in the psychiatric-mental health nurse's behavior toward a patient; the nurse is unreasonably concerned, overly kind, or irrationally hostile. The most appropriate explanation is that the nurse is displaying:
- A. countertransference
- B. empathic resonance
- C. splitting behavior
- D. transference
Correct Answer: A
Rationale: Countertransference involves the nurse's emotional reactions to the patient based on personal unconscious feelings, leading to inconsistent behavior.