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Which of the following assessments is most appropriate for a patient with anorexia nervosa?
- A. Monitor fluid intake exclusively.
- B. Check weight daily without discussing it with the patient.
- C. Observe the patient's response to meals, including food refusal or purging behavior.
- D. Monitor for signs of vitamin and mineral deficiencies.
Correct Answer: C
Rationale: The correct answer is C because observing the patient's response to meals, including food refusal or purging behavior, is crucial in assessing the patient's eating habits and behaviors associated with anorexia nervosa. This assessment helps in understanding the patient's relationship with food and identifying any disordered eating patterns. Monitoring fluid intake exclusively (Choice A) is not sufficient as it overlooks the broader aspects of the patient's eating behaviors. Checking weight daily without discussing it with the patient (Choice B) can be triggering and may not provide a comprehensive understanding of the patient's eating disorder. Monitoring for signs of vitamin and mineral deficiencies (Choice D) is important but does not directly address the specific behaviors associated with anorexia nervosa.
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A man with hypospadias tells the nurse, 'Intercourse with my new bride is painful.' Which term applies to the patient's complaint?
- A. Dyspareunia
- B. Erectile dysfunction
- C. Premature ejaculation
- D. Genito-pelvic pain/penetration disorder
Correct Answer: D
Rationale: The correct answer is D: Genito-pelvic pain/penetration disorder. This term is applicable because it specifically refers to pain experienced during intercourse, which aligns with the patient's complaint. Hypospadias can lead to difficulties in penetration and subsequent pain during intercourse.
Choice A: Dyspareunia refers to persistent or recurrent pain during sexual intercourse, which is a broader term than what the patient is experiencing.
Choice B: Erectile dysfunction is the inability to achieve or maintain an erection, which is not directly related to the patient's complaint of pain during intercourse.
Choice C: Premature ejaculation is the early release of semen during sexual activity, which is unrelated to the pain experienced by the patient during intercourse.
An advance directive gives legally binding direction for health care interventions when a patient:
- A. has a new diagnosis of cancer
- B. is diagnosed with Parkinsons disease
- C. is unable to make decisions for self because of illness
- D. diagnosed with amyotrophic lateral sclerosis is unable to speak
Correct Answer: C
Rationale: Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinsons disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.
The nursing diagnosis Rape-trauma syndrome is established for a rape victim in the emergency department. Select the most important outcome to achieve before discharging the patient!
- A. The patient will describe feelings of safety and relaxation.
- B. The memory of the rape will be less vivid and less frightening.
- C. Physical symptoms of pain and discomfort are no longer present.
- D. The patient will agree to keep a follow-up appointment with a rape victim advocate.
Correct Answer: D
Rationale: The correct answer is D. Establishing a follow-up appointment with a rape victim advocate is crucial for ongoing support and recovery. It ensures the patient has access to necessary resources and assistance in coping with the trauma. Choice A focuses on emotional well-being but doesn't address long-term support. Choice B addresses memory but doesn't ensure ongoing care. Choice C only addresses physical symptoms, neglecting the emotional and psychological impact of the trauma. Thus, choice D is the most important outcome to achieve before discharging the patient to promote comprehensive care and support.
If a person suffering from schizophrenia has an identical twin, that twin
- A. will have a 46 percent chance of becoming schizophrenic
- B. will be no more likely than anyone else to become schizophrenic
- C. is almost sure to become schizophrenic
- D. is also likely to have more than one personality
Correct Answer: A
Rationale: Identical twins share genetics, giving a 46% concordance rate for schizophrenia, reflecting strong genetic influence.
When a patient with anorexia nervosa is admitted for treatment, the milieu should provide: (Select all that apply.)
- A. Flexible mealtimes.
- B. Unscheduled weight checks.
- C. Adherence to a selected menu.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Flexible mealtimes. In the treatment of anorexia nervosa, providing flexible mealtimes allows patients to regain a sense of control over their eating habits, which is crucial in their recovery process. This approach helps to reduce anxiety around food and promotes a healthier relationship with eating.
Choice B: Unscheduled weight checks can be triggering and anxiety-provoking for patients with anorexia nervosa, as weight monitoring can be a significant source of distress for them.
Choice C: Adherence to a selected menu may reinforce rigid eating patterns and control issues related to food, which can be counterproductive in the treatment of anorexia nervosa.
Choice D: None of the above is incorrect because providing flexible mealtimes is essential in creating a supportive and therapeutic environment for patients with anorexia nervosa.