Nursing Elites

1. A patient with anorexia nervosa is being treated in an inpatient facility. Which intervention should be included in the care plan?

• A. Allowing the patient to eat alone to reduce stress
• B. Monitoring the patient's weight weekly
• C. Encouraging the patient to exercise daily
• D. Providing the patient with a high-calorie diet

Correct answer: B

Rationale: Monitoring the patient's weight weekly is crucial in the care of individuals with anorexia nervosa as it allows healthcare providers to track changes in weight, which is a key indicator of nutritional status. Regular weight monitoring helps in identifying any significant weight loss or gain, enabling prompt intervention and adjustment of the treatment plan to address the patient's nutritional needs effectively.

2. After a severe automobile accident, Mr. and Mrs. Johnson were brought to the hospital. Mrs. Johnson is unable to remember anything about the accident or the two days preceding it. The nurse recognizes this as:

• A. Generalized amnesia
• B. Localized amnesia
• C. Selective amnesia
• D. Continuous amnesia

Correct answer: B

Rationale: Localized amnesia refers to an inability to recall specific events, often traumatic, within a particular time frame. In this case, Mrs. Johnson's memory loss about the accident and the preceding two days aligns with the characteristics of localized amnesia. Generalized amnesia involves a more extensive memory loss, often encompassing a person's entire life, which is not the case here. Selective amnesia involves forgetting specific details but not a whole chunk of time like in this scenario. Continuous amnesia is not a recognized term in psychology.

3. The nurse is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the nurse stress to the patient?

• A. Increased attentiveness
• B. Getting up at night to urinate
• C. Improved vision
• D. An upset stomach for no apparent reason

Correct answer: D

Rationale: The correct early sign of lithium toxicity that the nurse should stress to the patient is an upset stomach for no apparent reason. Early signs of lithium toxicity often manifest as gastrointestinal symptoms such as nausea, vomiting, and diarrhea. This can serve as an important indicator for the patient to seek medical attention promptly to prevent further complications. Choices A, B, and C are incorrect. Increased attentiveness, getting up at night to urinate, and improved vision are not early signs of lithium toxicity. It is crucial for the nurse to educate the patient on recognizing gastrointestinal symptoms as potential indicators of toxicity.

4. James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for the day shift and anxiously reports, “Last night, demons came to my room and tried to rape me.” Which response would be most therapeutic?

• A. There are no such things as demons. What you saw were hallucinations.
• B. It is not possible for anyone to enter your room at night. You are safe here.
• C. You seem very upset. Please tell me more about what you experienced last night.
• D. That must have been very frightening, but we’ll check on you at night and you’ll be safe.

Correct answer: C

Rationale: The most therapeutic response acknowledges the patient's emotional state and invites further discussion about their experience. By saying, 'You seem very upset. Please tell me more about what you experienced last night,' the nurse shows empathy and openness, providing a supportive environment for the patient to express their feelings and perceptions.

5. During a panic attack, what is the most appropriate nursing intervention?

• A. Encourage the patient to talk about their feelings.
• B. Provide a quiet, non-stimulating environment.
• C. Administer prescribed medication immediately.
• D. Teach the patient relaxation techniques.

Correct answer: B

Rationale: During a panic attack, a quiet, non-stimulating environment is the most appropriate nursing intervention. This helps reduce stimuli that may exacerbate the panic attack and allows the individual to focus on calming down. Encouraging the patient to talk about their feelings may not be effective during an acute panic attack as the focus should be on reducing stimuli. Administering medication should follow healthcare provider's orders and may not be the initial intervention. Teaching relaxation techniques is beneficial in managing anxiety but may not be the priority during the acute phase of a panic attack where reducing stimuli is crucial.

Similar Questions