Question: Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor?
Answer Choices: a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. The patient expresses satisfaction with body appearance.
Answer: d. The patient expresses satisfaction with body appearance
Question: A patient who was referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient’s oral intake, the nurse should ask which assessment question?
Answer Choices: a. “Do you often feel fat?” b. “Who plans the family meals?” c. “What do you eat in a typical day?” d. “What do you think about your present weight?”
Answer: c. “What do you eat in a typical day?”
Question: A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, “Describe what you think about your present weight and how you look.” Which response by the patient is most consistent with the diagnosis?
Answer Choices: a. “I am fat and ugly.” b. “What I think about myself is my business.” c. “I am grossly underweight, but that’s what I want.” d. “I am a few pounds overweight, but I can live with it.”
Answer: a. “I am fat and ugly.”
Question: A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient’s current serum potassium is 2.7 mg/dL. Which nursing diagnosis is most applicable?
Answer Choices: a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia
Answer: d. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia
Question: Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: imbalanced nutrition: less than body requirements. Within 1 week, the expectation is that the patient will demonstrate what?
Answer Choices: a. Weigh self accurately using balanced scales b. Limit exercise to less than 2 hours daily
Answer: a. Weigh self accurately using balanced scales
Question: Which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight?
Answer Choices: a. Assess for depression and anxiety b. Observe for adverse effects of refeeding c. Communicate empathy for the patient’s feelings d. Help the patient balance energy expenditure and caloric intake
Answer: b. Observe for adverse effects of refeeding
Question: A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?
Answer Choices: a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected b. Patient involvement in decision making increases a sense of control and promotes compliance with the treatment c. A team approach to planning the diet ensures that physical and emotional needs of the patient are met d. Because of increased risk for physical problems with refeeding, obtaining patient permission is required
Answer: b. Patient involvement in decision making increases a sense of control and promotes compliance with the treatment
Question: The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention “Monitor for complications of refeeding.” Which body system should a nurse closely monitor for dysfunction?
Answer Choices: a. Renal b. Endocrine c. Central nervous d. Cardiovascular
Answer: d. Cardiovascular
Question: A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy?
Answer Choices: a. “What are your feelings about not eating the food that you prepare?” b. “You seem to feel much better about yourself when you eat something.” c. “It must be difficult to talk about private matters to someone you just met.” d. “Being thin does not seem to solve your problems. You are thin now but still unhappy.”
Answer: d. “Being thin does not seem to solve your problems. You are thin now but still unhappy.”
Question: An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient what intervention?
Answer Choices: a. Eat a small meal after purging b. Avoid skipping meals or restricting food c. Concentrate oral intake after 4 pm daily d. Understand the value of reading journal entries aloud to others
Answer: b. Avoid skipping meals or restricting food
Question: A tearful, anxious patient at the outpatient clinic reports, “I should be dead.” The initial task of the nurse conducting the assessment interview is to focus on what? a. Assessing the lethality of any suicide plan b. Encouraging expression of anger c. Establishing a rapport with the patient d. Determining risk factors for suicide Correct Answer C
Answer Choices: Not provided.
Answer: Not provided in source.
Question: What is the most helpful response for a nurse to make when a patient being treated as an outpatient states, “I am considering suicide.”? a. “I’m glad you shared this. Please do not worry. We will handle it together.” b. “I think you should admit yourself to the hospital to get help.” c. “We need to talk about the good things you have to live for.” d. “Bringing this up is a very positive action on your part.” Correct Answer D
Answer Choices: Not provided.
Answer: Not provided in source.
Question: Which intervention should a nurse recommend for the distressed family and friends of someone who has successfully committed suicide? a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessment Correct Answer B
Answer Choices: Not provided.
Answer: Not provided in source.
Question: Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act. Correct Answer A
Answer Choices: Not provided.
Answer: Not provided in source.
Question: A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, “My business is bankrupt, and I was served with divorce papers.” Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. “I wish I were dead.” b. “Life is not worth living.” c. “I have a plan that will fix everything.” d. “My family will be better off without me.” Correct Answer C
Answer Choices: Not provided.
Answer: Not provided in source.
Question: A depressed patient says, “Nothing matters anymore. What is the most appropriate response by the nurse? a. “Are you having thoughts of suicide?” b. “I am not sure I understand what you are trying to say.” c. “Try to stay hopeful. Things have a way of working out.” d. “Tell me more about what interested you before you began feeling depressed.” Correct Answer A
Answer Choices: Not provided.
Answer: Not provided in source.
Question: A nurse counsels a patient with recent suicidal ideation. Which is the nurse’s most therapeutic comment? a. “Let’s make a list of all your problems and think of solutions for each one.” b. “I’m happy you’re taking control of your problems and trying to find solutions.” c. “When you have bad feelings, try to focus on positive experiences from your life.” d. “Let’s consider which problems are most important and focus on discussing them.” Correct Answer D
Answer Choices: Not provided.
Answer: Not provided in source.
Question: When assessing a patient’s plan for suicide, what aspect has priority? a. Patient’s financial and educational status b. Patient’s insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient’s social support Correct Answer C
Answer Choices: Not provided.
Answer: Not provided in source.
Question: Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? a. Every suicidal person is mentally ill. b. Every suicidal person is intent on dying. c. Every suicidal person is cognitively impaired. d. Every suicidal person experiencing hopelessness. Correct Answer D
Answer Choices: Not provided.
Answer: Not provided in source.
Question: Which statement by a patient during an assessment interview should alert the nurse to the patient’s need for immediate, active intervention? a. “I am mixed up, but I know I need help.” b. “I have no one for help or support.” c. “It is worse when you are a person of color.” d. “I tried to get attention before I shot myself.” Correct Answer B
Answer Choices: Not provided.
Answer: Not provided in source.