quiz 6

1. What is a nurse's legal responsibility if child abuse or neglect is suspected? A. Discuss the findings with the child's parent and health care provider. B. Document the observation and suspicion in the medical record. C. Report the suspicion according to state regulations. D. Continue the assessment.

C. Report the suspicion according to state regulations.

1. A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? A. "You and I will have to sit down and discuss this problem." B. "It bothers me to see you exercising. I am afraid you will lose more weight." C. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." D. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

A. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

1. Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? A. "You are feeling violated because you thought you could trust your partner." B. "I'm here for you. I want you to tell me about the bad things that happened to you." C. "I was very worried about you. I knew you were living in a potentially violent situation." D. "Abusers often target people who are passive. I will refer you to an assertiveness class."

A. "You are feeling violated because you thought you could trust your partner."

1. An adult says to the nurse, "The cancer in my neck spread in only 2 months. I've been cursed my whole life. Maybe if I had been more generous with others ..." Considering the stages of grief described by Kübler-Ross, which stage is evident? A. Anger B. Denial C. Depression D. Bargaining

A. Anger

1. Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? A. Assist the patient to identify triggers to binge eating. B. Provide corrective consequences for weight loss. C. Assess for signs of impulsive eating. D. Explore needs for health teaching.

A. Assist the patient to identify triggers to binge eating.

1. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should A. assess lung sounds and extremities. B. suggest use of an aerobic exercise program. C. positively reinforce the patient for the weight gain. D. establish a higher goal for weight gain the next week.

A. assess lung sounds and extremities.

1. After a spouse's death, an adult repeatedly says, "I should have recognized what was happening and been more helpful." This adult is experiencing: A. depression. B. bargaining. C. anger. D. guilt.

A. bargaining.

1. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who A. have been abused. B. are attention seeking. C. have eating disorders. D. are developmentally delayed.

A. have been abused.

1. A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to A. self-monitoring of daily food and fluid intake. B. establishing the desired daily weight gain. C. how to recognize hypokalemia. D. self-esteem maintenance.

A. how to recognize hypokalemia.

1. Physical assessment of a patient diagnosed with bulimia often reveals A. prominent parotid glands. B. peripheral edema. C. thin, brittle hair. D. 25% underweight.

A. prominent parotid glands.

1. An older adult diagnosed with Alzheimer's disease lives with family in a rural area. During the week, this adult attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this adult most vulnerable to abuse? A. Multiple caregivers B. Alzheimer's disease C. Living in a rural area D. Being part of a busy family

B. Alzheimer's disease

1. Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? 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 expenditures with caloric intake.

B. Observe for adverse effects of refeeding.

1. 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? A. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. B. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care. C. Because of increased risk of physical problems with refeeding, the patient's permission is needed. D. A team approach to planning the diet ensures that physical and emotional needs will be met.

B. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care.

1. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? A. Self-awareness enhances the nurse's advocacy role. B. Strong negative feelings interfere with assessment and judgment. C. Strong positive feelings lead to healthy transference with the victim. D. Positive feelings promote the development of sympathy for patients.

B. Strong negative feelings interfere with assessment and judgment.

1. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? A. A support group B. A mental health center C. A women's shelter D. Vocational counseling

C. A women's shelter

1. An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? A. Tension-building B. Acute battering C. Honeymoon D. Stabilization

C. Honeymoon

1. As a patient admitted to the eating-disorder unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5'4" tall. Which term should be documented? A. Amenorrhea B. Alopecia C. Lanugo D. Stupor

C. Lanugo

1. A patient who was widowed 18 months ago says, "I can remember good times we had without getting upset. Sometimes I even think about the disappointments. I am still trying to become accustomed to sleeping in the bed all alone." The work of mourning A. is beginning. B. has not begun. C. is at or near completion. D. is progressing abnormally.

C. is at or near completion.

1. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? A. Call the police. B. Arrange for hospitalization. C. Call the adult protective agency. D. Document injuries with a body map.

D. Document injuries with a body map.

1. Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? A. Urine output 40 mL/hour B. Pulse rate 58 beats/min C. Serum potassium 3.4 mEq/L D. Systolic blood pressure 62 mm Hg

D. Systolic blood pressure 62 mm Hg

1. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will A. weigh self accurately using balanced scales. B. limit exercise to less than 2 hours daily. C. select clothing that fits properly. D. gain 1 to 2 pounds.

D. gain 1 to 2 pounds.