Which of the following is an expected finding for a patient with anorexia nervosa?
- A. Increased appetite and food cravings.
- B. A body mass index (BMI) in the normal range.
- C. Bradycardia and hypotension.
- D. Elevated blood pressure and rapid pulse.
Correct Answer: C
Rationale: The correct answer is C. Patients with anorexia nervosa often have bradycardia and hypotension due to the physiological effects of severe malnutrition. Explanation: Severe restriction of food intake leads to decreased energy stores, causing the body to slow down its metabolic processes, including heart rate and blood pressure. Bradycardia and hypotension are common findings in individuals with anorexia nervosa.
Summary:
A: Increased appetite and food cravings are not expected findings in anorexia nervosa as patients typically have a decreased appetite.
B: A body mass index (BMI) in the normal range is not expected in anorexia nervosa, as patients often have a low BMI due to significant weight loss.
D: Elevated blood pressure and rapid pulse are not typical findings in anorexia nervosa; rather, patients may present with low blood pressure and bradycardia.
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A patient with bipolar disorder is hyperactive and has not slept for 3 days. Mood and behavior are labile. The patient threatens to hit another patient. Which response by the nurse is appropriate?
- A. Stop that now. No one did anything to provoke an attack by you.
- B. If you try that again, you will be placed in seclusion immediately.
- C. Do not hit anyone. If you are unable to control yourself, we will help you.
- D. You know we will not let you hit anyone. Why do you continue this behavior?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the patient's struggle to control their behavior and offers support. It emphasizes the importance of not hitting anyone while also reassuring the patient that help is available if needed. This response promotes a therapeutic environment by setting clear boundaries and offering assistance rather than using threats or aggression.
Choice A is incorrect as it may escalate the situation by using a confrontational tone, potentially provoking further aggression. Choice B is also incorrect as it threatens the patient with seclusion, which can be seen as punitive and may not address the underlying issues causing the behavior. Choice D is incorrect as it does not provide a clear directive to prevent violence and instead questions the patient's behavior without offering immediate support.
Mood disorders are those in which the person may
- A. experience severe depression and threaten suicide
- B. exhibit symptoms suggesting physical disease or injury but for which there is no identifiable cause
- C. exhibit behavior that is the result of an organic brain pathology
- D. experience delusions and hallucinations
Correct Answer: A
Rationale: Mood disorders, like depression, feature extreme emotional states, including suicidal ideation.
A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after experiencing an event in which self-esteem is challenged. The most recent episodes of violence were related to feeling 'upset' over a job loss. What type of therapy would provide the greatest help to the victim?
- A. Individual therapy
- B. Group therapy
- C. Couples therapy
- D. Family therapy
Correct Answer: A
Rationale: The correct answer is A: Individual therapy. In this scenario, individual therapy would be most beneficial because it allows the victim to focus on healing and developing coping strategies for dealing with the abuse and rebuilding self-esteem. Addressing the victim's psychological well-being and empowering them to recognize and address the abusive behavior is crucial. Group therapy (B) may not provide the necessary individualized support. Couples therapy (C) could potentially put the victim at further risk of harm. Family therapy (D) may not address the specific dynamics of the abusive relationship.
What is the priority nursing intervention for a patient with bulimia nervosa who is engaging in purging behaviors?
- A. Monitor electrolyte levels and cardiac function.
- B. Encourage self-monitoring of food intake.
- C. Provide emotional support and promote body image acceptance.
- D. Focus on encouraging weight loss through diet control.
Correct Answer: A
Rationale: The correct answer is A. The priority nursing intervention for a patient with bulimia nervosa engaging in purging behaviors is to monitor electrolyte levels and cardiac function. This is crucial due to the potential electrolyte imbalances and cardiac complications resulting from purging behaviors. Monitoring these parameters helps prevent life-threatening conditions such as hypokalemia and arrhythmias.
Option B is incorrect as self-monitoring of food intake may not address the immediate health risks associated with purging behaviors. Option C is also incorrect as emotional support and body image acceptance are important but not the immediate priority in this case. Option D is incorrect as focusing on weight loss through diet control can exacerbate the patient's eating disorder behaviors and does not address the urgent medical concerns associated with purging.
A patient diagnosed with dementia associated with excessive alcohol use tells a nurse, "Last week I had to take my baby to the hospital for major surgery. That's why I've been so nervous and needed to come here."Â The nurse is aware that the patient has never parented any children. The symptom described can be assessed as:
- A. akathisia.
- B. confabulation.
- C. intellectualization.
- D. magical thinking.
Correct Answer: B
Rationale: The correct answer is B: confabulation. Confabulation is the production of fabricated or distorted memories without the conscious intention to deceive. In this case, the patient is creating a false memory about having a baby and needing to take it to the hospital, which is not based on reality. Akathisia (A) is a movement disorder associated with restlessness, not memory distortion. Intellectualization (C) is a defense mechanism involving excessive focus on facts to avoid uncomfortable emotions, not memory fabrication. Magical thinking (D) involves believing that one's thoughts can influence events, not creating false memories.