Nokea
Which of the following statements by a patient with anorexia nervosa indicates a need for further education?
- A. I want to gain weight, but only if I can stay under 120 pounds.
- B. I understand that my body weight is dangerously low.
- C. I know that food is the enemy and I need to avoid it at all costs.
- D. I am willing to work with my healthcare team to improve my nutrition.
Correct Answer: C
Rationale: The correct answer is C because it indicates a misunderstanding of anorexia nervosa. Patients with anorexia often see food as the enemy, which is a distorted perception. Understanding that food is necessary for nourishment and health is crucial in recovery. Choice A shows an unhealthy weight goal, choice B shows awareness of low weight, and choice D shows willingness to work with the healthcare team, all of which are positive signs.
You may also like to solve these questions
A client with obsessive-compulsive personality disorder is described by other staff as being perfectionistic, inflexible, and a 'master at procrastination.' The nurse learns that the client is nearly immobilized during times that call for the client to make a decision. The nurse realizes that the most likely hypothesis is this behavior is related to:
- A. A need to make others uncomfortable
- B. Needing to be the center of attention
- C. Wanting someone else to be responsible
- D. Fear of making a mistake
Correct Answer: D
Rationale: The correct answer is D: Fear of making a mistake. This is the most likely hypothesis because individuals with obsessive-compulsive personality disorder often have an intense fear of making errors or mistakes. This fear can lead to excessive preoccupation with details, perfectionism, and procrastination. The client's immobilization during decision-making moments is likely due to the overwhelming anxiety and fear of making the wrong choice, which is a common trait in individuals with this disorder.
Choice A (A need to make others uncomfortable) is incorrect because there is no indication that the client's behavior is driven by a desire to cause discomfort to others. Choice B (Needing to be the center of attention) is incorrect as individuals with obsessive-compulsive personality disorder typically focus more on their own perfectionism rather than seeking attention. Choice C (Wanting someone else to be responsible) is incorrect as this behavior is more about the individual's fear of making mistakes rather than avoiding responsibility.
The mother of a client newly diagnosed with schizophrenia is a nurse. She unhappily tells the nurse on the unit, 'I've tried to be a good mother, but my daughter still developed schizophrenia. When I was in school, we were taught that it was the mother's fault if a child became schizophrenic. I wish I knew what I did wrong.' The response that would help the mother evaluate models explaining schizophrenia would be:
- A. I can see how you would be upset over this turn of events.'
- B. New findings suggest this disorder is biologic in nature.'
- C. Don't be so hard on yourself; your daughter needs you to be strong.'
- D. It's difficult to see that double-bind communication produces stress for the child at the time it's occurring.'
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Choice B is the correct answer because it provides the mother with new information that schizophrenia is biologic in nature, shifting the blame away from her.
2. This response helps the mother understand that her daughter's condition is not her fault, based on current scientific understanding.
3. By offering this information, the nurse helps the mother reevaluate her beliefs and perceptions about the causes of schizophrenia.
4. Choices A, C, and D do not address the mother's concerns directly or provide her with the necessary information to understand the biological basis of schizophrenia.
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy."Â A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
- A. take the patient's vital signs.
- B. start intravenous fluids.
- C. administer a sedative.
- D. perform a mental status examination.
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
Which of the following is a common complication of anorexia nervosa?
- A. Hypertension and hyperglycemia.
- B. Cardiovascular instability and electrolyte imbalances.
- C. Insulin resistance and excessive weight gain.
- D. Severe dehydration and frequent urination.
Correct Answer: B
Rationale: The correct answer is B: Cardiovascular instability and electrolyte imbalances. Anorexia nervosa can lead to severe malnutrition, causing cardiovascular issues like low heart rate and blood pressure. Electrolyte imbalances occur due to inadequate nutrient intake. Hypertension and hyperglycemia (choice A) are not common in anorexia. Insulin resistance and weight gain (choice C) are more associated with conditions like obesity. Severe dehydration and frequent urination (choice D) are not typical manifestations of anorexia.
Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should
- A. develop an understanding of human sexual response.
- B. assess the patient's sexual functioning and needs.
- C. acquire knowledge of the patient's sexual roles.
- D. clarify own personal values about sexuality.
Correct Answer: D
Rationale: The correct answer is D because clarifying the nurse's own personal values about sexuality is crucial before addressing a patient's sexual dysfunction. By understanding personal biases or judgments, the nurse can provide unbiased care. Assessing the patient's needs (B) should follow, as it directly addresses the patient's concerns. Developing an understanding of human sexual response (A) is important, but not as urgent as addressing personal values. Acquiring knowledge of the patient's sexual roles (C) is less relevant and should come after understanding the patient's needs.