Answer:
The duty of care is owed to the patient.
Question: A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.)
Answer Choices:
a. Hypothermia
b. Parotid swelling
c. Constipation
d. Hypotension
e. Dental caries
f. Languor
Answer:
A, C, D, F
Question: Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective?
Answer Choices:
a. “I think the staff at the center is really trying to help me.”
b. “I’m never going to get high on drugs again.”
c. “I hate my doctor for not giving me what I ask for.”
d. “I felt empty and wanted to cut myself, so I called you.”
Answer:
d. “I felt empty and wanted to cut myself, so I called you.”
Question: A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Today the patient telephones to say, “I’m feeling empty and want to cut myself.” The nurse should implement what intervention?
Answer Choices:
a. Arrange for emergency inpatient hospitalization.
b. Send the patient to the crisis intervention unit for 8 to 12 hours.
c. Assist the patient to identify the trigger situation and choose a coping strategy.
d. Advise the patient to take an antianxiety medication to decrease the anxiety level.
Answer:
c. Assist the patient to identify the trigger situation and choose a coping strategy.
Question: A patient diagnosed with anorexia nervosa. The body weight is below 85% of the ideal body weight. Serum potassium is 2.7 m/dL. Which nursing diagnosis is most appropriate? a. Disturbed energy field, related to physical exertion and excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia b. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia c. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia d. Imbalanced electrolyte, related to self-induced vomiting, evidenced by failure to thrive at this time.
Answer Choices:
a. Disturbed energy field, related to physical exertion and excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia
b. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia
c. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia
d. Imbalanced electrolyte, related to self-induced vomiting, evidenced by failure to thrive at this time.
Answer:
C
Question: Which entry in the medical record best meets the requirement for problem-oriented charting?
Answer Choices:
a. “A: Pacing and muttering to self. P: Sensory perceptual alteration, related to chemical auditory stimulation. I: Given fluphenazine 2.5 mg at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.”
b. “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg. I: haloperidol 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.”
c. “Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV.”
d. “Pacing hall and muttering to self as though answering an unseen person. haloperidol 2 mg administered at 0900 with calming effect in 30 minutes. Stated, ‘I’m no longer bothered by the voices.’”
Answer:
b. “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg. I: haloperidol 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.”
Question: Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings?
Answer Choices:
a. Ability to achieve true intimacy
b. Flexibility and adaptability to stress
c. Ability to evoke interpersonal conflict
d. Inability to develop trusting relationships
Answer:
c. Ability to evoke interpersonal conflict
Question: A newly admitted patient diagnosed with schizophrenia says, “The nurses are bothering me. They yell and tell me I’m bad. I have got to get away from them.” Select the nurse’s most helpful reply. A) “Do you hear the voices often?” B) “You seem to be feeling pretty upset right now.” C) “I will stay with you. Focus on what we are talking about, not the voices.” D) “Forget about the voices. Ask some other patients to sit and talk with you.”
Answer Choices:
A) “Do you hear the voices often?”
B) “You seem to be feeling pretty upset right now.”
C) “I will stay with you. Focus on what we are talking about, not the voices.”
D) “Forget about the voices. Ask some other patients to sit and talk with you.”
Answer:
C
Question: A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting?
Answer Choices:
a. Flattering the nurse
b. Lying to other patients
c. Verbal abuse of another patient
d. Detached superficiality during counseling
Answer:
c. Verbal abuse of another patient
Question: A nurse prepares to administer an antipsychotic medication to a patient diagnosed with schizophrenia. Additional monitoring of the medication’s effects and side effects will be most important if the patient is also diagnosed with which health problem? (Select all that apply.)
Answer Choices:
a. Parkinson disease
b. Graves’ disease
c. Osteoarthritis
d. Epilepsy
e. Diabetes
Answer:
a. Parkinson disease, d. Epilepsy, e. Diabetes
Question: A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient’s head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which effect is the patient demonstrating? A) Acute dystonic reaction B) Tardive dyskinesia C) Waxy flexibility D) Akathisia
Answer Choices:
A) Acute dystonic reaction
B) Tardive dyskinesia
C) Waxy flexibility
D) Akathisia
Answer:
A
Question: A patient diagnosed with schizophrenia is hospitalized after arguing with coworkers and threatening to harm them. The patient is aloof and suspicious and says, “Two staff members I saw talking were plotting to assault me.” Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)
Answer Choices:
A. Risk for other-directed violence
B. Disturbed thought processes
C. Risk for loneliness
D. Spiritual distress
E. Social isolation
Answer:
A, B