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.
You may also like to solve these questions
A client, age 70, was brought into the Emergency Department by family members who reported a fall. During the assessment the nurse became suspicious that the client had suffered physical abuse. The client denied that she had been abused. Her denial is most likely based on her:
- A. Strong belief that nothing could be done to help her
- B. Fear of the possibility of being removed from her family
- C. Feeling that she deserved the physical abuse
- D. Lack of trust that the situation could be changed
Correct Answer: B
Rationale: The correct answer is B: Fear of the possibility of being removed from her family. This is because elderly individuals who are experiencing abuse may fear being separated from their family if they disclose the abuse. This fear of losing their support system can lead them to deny or minimize the abuse. This choice is the most likely reason for the client's denial in this scenario.
Choice A: Strong belief that nothing could be done to help her is incorrect because the client's denial is not based on a belief that nothing could be done, but rather on a fear of being removed from her family.
Choice C: Feeling that she deserved the physical abuse is incorrect as victims of abuse often do not feel they deserve the abuse, but rather may feel ashamed or fearful.
Choice D: Lack of trust that the situation could be changed is incorrect because the client's denial is more likely based on a fear of losing her family, rather than a lack of trust in the situation changing.
Marty is a 15-year-old boy whose parents have brought him to a mental health clinic for evaluation. They are concerned because his grades have fallen and he has become angry and sometimes even violent. He spends long periods of time alone and does not want to see his friends. The parents report that he has never been a bad boy nor had problems in school. They are worried about the changes in his behavior. Which of the following is the most likely cause?
- A. Depression
- B. Running around with a tough crowd
- C. Normal adolescent phase
- D. Attention deficit hyperactivity disorder
Correct Answer: A
Rationale: In addition to classic symptoms of depression, adolescents often display irritability and problems in school performance. This is not normal teen behavior. Because Marty has been functioning well in school up until now, it is unlikely that ADHD would be exhibited at this point.
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.
A child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty when the community mental health nurse visits to investigate the child's school absences. The nurse's legal responsibility if child abuse or neglect is suspected is to:
- A. consult with the child's teacher, principal, and school psychologist.
- B. document the observations and impressions in the family health record.
- C. report her suspicions of abuse or neglect according to state regulations.
- D. wait until she has proof of abuse or neglect, then report it to authorities.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. **Legal Obligation**: The nurse has a legal duty to report suspicions of child abuse or neglect.
2. **Protecting the Child**: Reporting ensures the child's safety and well-being.
3. **State Regulations**: State laws mandate reporting suspected abuse or neglect.
4. **Immediate Action**: Waiting for proof delays intervention and puts the child at risk.
Summary:
- Choice A: Consulting with school staff doesn't fulfill the legal obligation to report.
- Choice B: Documenting is important but not sufficient; reporting is crucial.
- Choice D: Waiting for proof is dangerous; immediate reporting is necessary to protect the child.
A new nurse asks the experienced nurse who is caring for a battered woman client, 'Why did you ask about culture when it was obvious you needed to focus on the battering?' The experienced nurse should respond:
- A. It's just a habit I got into a while ago.'
- B. It helps me focus on whether to do a complete physical assessment.'
- C. Culture is a determinant of how women interpret and respond to violence.'
- D. If I know more about her I can refer her to a shelter that caters to her ethnic group.'
Correct Answer: C
Rationale: Rationale:
- Choice C is correct because culture influences how individuals perceive and respond to violence, impacting their help-seeking behaviors and coping mechanisms.
- Understanding the client's cultural background is crucial for providing appropriate care and support.
- Choices A, B, and D are incorrect as they do not address the importance of considering culture in understanding and addressing domestic violence in this context.