Nokea
Which nursing intervention should be included in the care plan for a patient with anorexia nervosa who is at risk for refeeding syndrome?
- A. Refeed with high-calorie foods initially.
- B. Monitor serum electrolytes closely after refeeding begins.
- C. Increase fluid intake gradually over several days.
- D. Encourage early ambulation to prevent complications.
Correct Answer: B
Rationale: The correct answer is B: Monitor serum electrolytes closely after refeeding begins. Refeeding syndrome can occur in patients with anorexia nervosa when there is a rapid shift in electrolytes and fluid levels. Monitoring serum electrolytes closely after refeeding begins allows for early detection of any imbalances and prompt intervention. This helps prevent serious complications such as cardiac arrhythmias or neurological issues.
Choice A is incorrect because refeeding with high-calorie foods initially can exacerbate the risk of refeeding syndrome due to rapid changes in electrolyte levels. Choice C is incorrect as increasing fluid intake gradually may not directly address electrolyte imbalances. Choice D is incorrect as encouraging early ambulation is not directly related to preventing refeeding syndrome.
You may also like to solve these questions
The wife of a client diagnosed with paranoid schizophrenia asks, 'I've been told that my husband's illness is probably related to imbalanced brain chemicals. Can you be more specific?' The response based on the dopamine hypothesis is:
- A. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.'
- B. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect.'
- C. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations.'
- D. Breakdown of dopamine produces LSD, which in large amounts produces psychosis.'
Correct Answer: A
Rationale: Step-By-Step Rationale:
1. The dopamine hypothesis states that an increase in dopamine is linked to delusions and hallucinations in schizophrenia.
2. Delusions and hallucinations are common positive symptoms of schizophrenia.
3. Therefore, choice A is correct as it directly aligns with the dopamine hypothesis and the symptoms observed in paranoid schizophrenia.
Summary of Incorrect Choices:
B. Incorrect because an increase in dopamine is not typically associated with lack of motivation and disordered affect in schizophrenia.
C. Incorrect because decreased amounts of dopamine are not linked to delusions and hallucinations in schizophrenia.
D. Incorrect because the breakdown of dopamine producing LSD and causing psychosis is not supported by the dopamine hypothesis in schizophrenia.
A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?
- A. The patient is seeking the attention of staff.
- B. The patient is inappropriately expressing emotion.
- C. The patient is experiencing auditory hallucinations.
- D. The patient is displaying negative symptoms of schizophrenia.
Correct Answer: C
Rationale: The correct answer is C because the patient's behavior indicates a possible experience of auditory hallucinations. The patient covering both ears and shaking her head could be an attempt to block out voices or sounds she is hearing. The subsequent crying and muttering could be a response to these hallucinations.
Choice A is incorrect because the patient's behavior does not necessarily indicate a desire for attention. Choice B is incorrect because the patient's emotional expression is not the primary focus of the behavior. Choice D is incorrect because negative symptoms of schizophrenia typically involve a decrease in emotional expression or motivation, which is not evident in this scenario.
What is an appropriate goal for a nurse working with a patient who has bulimia nervosa?
- A. The patient will engage in daily exercise to control weight.
- B. The patient will eliminate purging behaviors and establish healthy eating habits.
- C. The patient will maintain a low weight and avoid binge episodes.
- D. The patient will adopt a restrictive diet to manage their eating behaviors.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Eliminating purging behaviors addresses the primary symptom of bulimia nervosa.
2. Establishing healthy eating habits promotes long-term recovery and overall well-being.
3. Focusing on behavior change rather than weight control aligns with evidence-based treatment.
4. This goal is client-centered, prioritizing the patient's mental and physical health.
Summary:
A: Focusing solely on exercise does not address the root cause of bulimia.
C: Emphasizing weight maintenance may reinforce unhealthy body image and behaviors.
D: Adopting a restrictive diet can exacerbate disordered eating patterns and harm health.
Which of the following interventions should the nurse plan to use to reduce client focus on delusional thinking?
- A. Confronting the delusion
- B. Focusing on feelings suggested by the delusion
- C. Refuting the delusion with logic
- D. Exploring reasons the client has the delusion
Correct Answer: B
Rationale: The correct answer is B: Focusing on feelings suggested by the delusion. By addressing the underlying emotions associated with the delusion, the nurse can help the client process and cope with their feelings, ultimately reducing the intensity of the delusional thinking. Confronting the delusion (A) may lead to resistance and escalation. Refuting the delusion with logic (C) can be ineffective as it may reinforce the client's belief. Exploring reasons for the delusion (D) may not directly address the client's focus on delusional thinking.
A normal person sees flashes of light while falling asleep. These are examples of
- A. Hypnopompic hallucinations
- B. Eidetic imagery
- C. Visual hallucinations
- D. Complex hallucinations
Correct Answer: C
Rationale: Flashes of light while falling asleep are hypnagogic visual hallucinations, a normal phenomenon, though 'visual hallucinations' is the closest match here.