Combo with "Chapter 12 - 13 - 14 -15 mental health

18. A nurse counseling a patient with a dissociative identity disorder should understand that the assessment of highest priority is: a. Risk for self-harm b. Cognitive functioning c. Identification of drug abuse d. Readiness to reestablish identity or memory

ANS: A Assessments that relate to patient safety take priority. Patients with dissociative identity disorders may be at risk for suicide or self-mutilation; therefore the nurse must be alert for hints of hopelessness, helplessness and worthlessness, low self-esteem, and impulses to self-mutilate. The distracters are important assessments but rank beneath safety.

19. A patient says, "I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study." Which term should the nurse use to document this complaint? a. Depersonalization b. Hypochondriasis c. Dissociation d. Malingering

ANS: A Depersonalization involves a persistent or recurrent experience of feeling detached from and outside one's mental processes or body. Although reality testing is intact, the detached experience causes significant impairment in social or occupational functioning and distress to the individual. Malingering involves a conscious process of intentionally producing symptoms for an obvious benefit; dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety. Hypochondriasis involves the interpretation of body sensations as symptomatic of a serious illness.

2. Which intervention is appropriate for a patient with an antisocial personality disorder who frequently manipulates others? a. Refer the patient's requests and questions related to care to the case manager. b. Encourage the patient to discuss his or her feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only one decision-maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored - judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, and never comes out for breaks or lunch. Which term best describes this behavior? a. Avoidant b. Dependent c. Histrionic d. Paranoid

ANS: A Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious and hostile and project blame.

13. A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

ANS: A Patients with functional neurologic (conversion) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed "la belle indifférence." In addition, a specific cause for the development of the symptoms is identifiable; in this instance, the death of a parent precipitates the stress.

21. What is the priority intervention for a nurse beginning to work with a patient with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Engage the patient in many community activities. d. Teach the patient how to match clothing.

ANS: A Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse.

15. A patient with borderline personality disorder is hospitalized several times after self-mutilating episodes. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder.

7. A patient with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic

ANS: A SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

22. The causes of somatic system disorders may be related to: a. faulty perceptions of body sensations. b. traumatic childhood events. c. culture-bound phenomena. d. depressive equivalents.

ANS: A Structural or functional abnormalities of the brain have been suggested to lead to the somatic system disorders, resulting in disturbed processes of perception and interpretation of bodily sensations. Furthermore, cognitive theorists believe patients misinterpret the meaning of certain bodily sensations and then become excessively alarmed by them. Traumatic childhood events are related to the dissociative disorders. Culture-bound phenomena may explain the prevalence of some symptoms but cannot explain the cause. Somatic system disorders are not another facet of depression; however, depression may coexist with a somatic system disorder.

11. Which assessment finding best supports dissociative fugue? The patient states: a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

ANS: A The patient in a fugue state frequently relocates and assumes a new identity while not recalling his or her previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.

14. A patient tells a nurse, "I sometimes get into trouble because I make quick decisions and act on them." A therapeutic response would be: a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I'll bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

ANS: A The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate the outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

2. A nurse assesses a patient suspected to have complex somatic system disorder. Which findings support the diagnosis? Select all that apply. a. Patient is a woman. b. Patient reports frequent syncope. c. Patient complains of heavy menstrual bleeding. d. Patient was first diagnosed with psoriasis at 12 years of age. e. Patient reports back pain, painful urination, frequent diarrhea, and hemorrhoids.

ANS: A, B, C, E No chronic disease explains the symptoms for patients with complex somatic system disorder. Patients report multiple symptoms; and gastrointestinal, sexual, and pseudoneurological symptoms are common. This disorder is more common is women than in men.

2. For which patients with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Dependent d. Schizotypal e. Narcissistic

ANS: A, B, D Some personality disorders have evidence of genetic links. Therefore the family history would show other family members with similar traits. Heredity plays a role in schizotypal and antisocial problems, as well as obsessive-compulsive personality disorder.

1. A patient with predominant pain disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

ANS: A, E The patient's verbalization is consistent with spiritual distress. Moreover, the patient's description of being unable to provide for and burdening the family suggests ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict.

14. A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care? a. Anxiety b. Risk for suicide c. Disturbed body image d. Ineffective role performance

ANS: B A high risk of completed suicide exists in patients with body dysmorphic disorder. Safety is always a high priority for the nurse; in this instance, the plan of care should include an awareness of the risk for self-inflicted harm.

23. A patient with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. encourage the patient to express anger. b. provide care in a matter-of-fact manner. c. be very kind, sympathetic, and concerned. d. offer to listen to the patient's feelings about cutting.

ANS: B A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this

17. A person comes to the clinic reporting, "I wear a scarf across my lower face when I go out but because of my ugly appearance." Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely? a. Dissociative identity disorder b. Body dysmorphic disorder c. Pseudocyesis d. Malingering

ANS: B Body dysmorphic disorder involves a preoccupation with an imagined defect in appearance. Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. Pseudocyesis is the false belief that one is pregnant. Malingering is intentionally producing symptoms for a personal gain.

12. A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later and sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered? a. Functional neurological (conversion) disorder b. Dissociative identity disorder c. Depersonalization disorder d. Body dysmorphic disorder

ANS: B Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. At least two of the subpersonalities take control of the person's behavior but leave the individual unable to remember the periods of time in which the subpersonality is in control.

25. Which treatment modality should a nurse recommend to help a patient with pain disorder cope more effectively? a. Flooding b. Relaxation c. Response prevention d. Systematic desensitization

ANS: B Pain increases when the patient has muscle tension. Relaxation can diminish the patient's perceptions of the intensity of pain. The distracters are modalities useful in treating selected anxiety disorders.

20. A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results are normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Functional neurologic (conversion) disorder b. Prominent health anxiety (hypochondriasis) c. Predominant (pain) disorder d. Dissociative fugue

ANS: B Patients with hypochondriasis have fears of serious medical problems such as cancer or heart disease. These fears persist, despite medical evaluations, and interfere with daily functioning. No complaints of pain are made, and no evidence of dissociation or conversion exists.

1. A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably: a. Readily seek psychiatric counseling. b. Be resistant to accepting psychiatric help. c. Attend psychotherapy sessions without encouragement. d. Be eager to discover the true reasons for physical symptoms.

ANS: B Patients with somatic system disorders go from physician to physician trying to establish a physical cause for their symptoms. When a psychologic basis is suggested and a referral for counseling is offered, these patients reject both.

2. A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? The patient is: a. suppressing accurate feelings regarding the problem. b. relieving anxiety through the physical symptom. c. meeting needs through hospitalization. d. refusing to disclose genuine fears.

ANS: B Psychoanalytic theory suggests conversion reduces anxiety through the production of a physical symptom that is symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously).

24. A patient says, "I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive restructuring? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking." b. "Let's see whether any other explanations for your vomiting are possible." c. "You seem so worried. Let's talk about how you're feeling." d. "We'll talk about something else."

ANS: B Questioning the evidence is a cognitive restructuring technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective.

26. Which commonality would be most applicable to the patient with a personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms.

ANS: B Self-esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. Personality disorders involve lifelong, inflexible, dysfunctional, and deviant patterns of behavior that cause distress to others and, in some cases, to self. Patients with personality disorders may experience very real anxiety and distress when stress levels rise. Some individuals with personality disorders, but not all, may decompensate and show psychotic behaviors under stress.

24. A nurse set limits for a patient with a borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're terrible." This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies.

ANS: B Splitting involves loving a person and then hating the person. The patient is unable to recognize that an individual can have both positive and negative qualities. Denial is an unconscious motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. Separation-individuation strategies refer to childhood behaviors related to developing independence from the caregiver.

19. A nurse in the emergency department tells an adult, "Your mother had a severe stroke." The adult tearfully says, "Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline

ANS: B The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.

3. A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed him- or herself after explaining the arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self unassisted. d. address the needs of other patients in the dining room, and then feed this patient.

ANS: B The patient is expected to maintain some level of independence by feeding him- or herself, whereas the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support.

4. A patient with blindness related to a functional neurological (conversion) disorder says, "All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital don't find me interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

ANS: B The patient mentions that the symptoms make people more interested, which indicates that the patient believes he or she is uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of Chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in this scenario.

9. A patient with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. Assume roles and functions of the other family members. b. Demonstrate a resumption of former roles and tasks. c. Focus energy on problems occurring in the family. d. Rely on family members to meet his or her personal needs.

ANS: B The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and the resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes.

9. What is the priority nursing diagnosis for a patient with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Disturbed sensory perception-auditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping

ANS: B Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority.

1. A nurse plans the care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

ANS: B, D Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists.

10. When a patient with a personality disorder uses manipulation to get his or her needs met, the staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patient's behavior.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.

4. What is an appropriate initial outcome for a patient with a personality disorder who frequently manipulates others? The patient will: a. Identify when feeling angry. b. Use manipulation only to get legitimate needs met. c. Acknowledge manipulative behavior when it is called to his or her attention. d. Accept fulfillment of his or her requests within an hour rather than immediately.

ANS: C Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The patient will ideally use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control.

10. A woman is 5'7" tall, weighs 160 pounds, and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." The patient tries to buy shoes to make her feet look smaller, and in social settings conceals both feet under a table or chair. Which health problem is likely? a. Dissociative fugue b. Prominent pain disorder c. Body dysmorphic disorder d. Depersonalization disorder

ANS: C Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient's feet are proportional to the rest of her body. Dissociative fugue is characterized by sudden, unexpected travel away from the customary locale and the inability to recall one's identity and information about some or all of the past. Prominent pain disorder involves the presence of pain not associated with a medical disorder. Depersonalization disorder involves an alteration in the perception of self, such as feeling mechanical or unreal.

27. A patient with predominant pain disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. unsuccessful. b. minimally successful. c. partially successful. d. totally achieved.

ANS: C Decreased preoccupation with symptoms and an increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.

25. Which characteristic of individuals with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to evoke interpersonal conflict d. Inability to develop trusting relationships

ANS: C Frequent team meetings are held to counteract the effects of the patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings.

6. A nurse reports to the interdisciplinary team that a patient with an antisocial personality disorder lies to other patients, verbally abuses a patient with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters.

12. The most challenging nursing intervention with patients with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy.

ANS: C Maintaining consistent limits is by far the most difficult intervention because of the patient's superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan. Positive reinforcement strategies for acceptable behavior are more effective than aversive techniques.

5. Consider these comments to three different nurses by a patient with an antisocial personality disorder: "You're a better nurse than the day shift nurse said you were": "Another nurse said you don't do your job right": "You think you're perfect, but I've seen you make three mistakes." Collectively, these interactions can be assessed as: a. Seductive b. Detached c. Manipulative d. Guilt producing

ANS: C Patients manipulate and control staff members in various ways. By keeping staff members off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evidenced in the comments.

21. A patient with predominant pain disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. Mood b. Cognitive style c. Secondary gains d. Identity and memory

ANS: C Secondary gains should be assessed. The patient's dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient's diagnosis has been established.

5. To assist a patient with a somatic system disorder, a nursing intervention of high priority is to: a. imply that somatic symptoms are not real. b. help the patient suppress feelings of anger. c. shift the focus from somatic symptoms to feelings. d. investigate each physical symptom as it is offered.

ANS: C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys an interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome is that the patient expresses feelings, including anger, if it is present. Once physical symptoms have been investigated, they do not need to be reinvestigated each time the patient reports them.

3. As a nurse prepares to administer a medication to a patient with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient's safety, as well as to prevent splitting other staff members. "Why" questions are not therapeutic.

11. A patient with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, "I'm feeling empty and want to cut myself." The nurse should: 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.

ANS: C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention, sedation may reduce the patient's ability to weigh alternatives to mutilating behavior.

3. A patient's roommate has observed the patient behaving in uncharacteristic ways, but the patient cannot remember the episodes. A dissociative identity disorder is suspected. Which questions are most relevant to the assessment of this patient? Select all that apply. a. "Are you sexually promiscuous?" b. "Do you think you need an antidepressant medication?" c. "Have you ever found yourself someplace and did not know how you got there?" d. "Are your memories of childhood clear and complete, or do you have blank spots?" e. "Have you ever found new things in your belongings that you can't remember buying?"

ANS: C, D, E Asking, "Are you sexually promiscuous?" would probably produce defensiveness on the part of the patient. If a subpersonality acts out sexually, the main personality is probably not aware of the behavior. "Do you think you need an antidepressant medication?" is a premature question and not in the nurse's scope of practice. All of the other questions are pertinent.

17. When preparing to interview a patient with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details, perfectionist. b. charm, drama, seductiveness, seeking admiration. c. difficulty being alone, indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

ANS: D According to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR), the characteristics of grandiosity, self-importance, and a sense of entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are observed in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are observed in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

8. To plan effective care for patients with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. Are generally chronic. b. Have a physiological basis. c. Can be voluntarily controlled. d. Provide relief from health anxiety.

ANS: D At the unconscious level, the patient's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide a secondary gain, patients frequently and fiercely cling to the symptoms. The symptoms tend to be chronic; however, this does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based.

22. A patient with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to: a. inherited disorder that manifests itself as an incapacity to tolerate stress b. use of projective identification and splitting to bring anxiety to manageable levels c. constitutional inability to regulate affect, predisposing to psychic disorganization d. fear of abandonment associated with progress toward autonomy and independence

ANS: D Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth.

15. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity, related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

ANS: D Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.

6. A patient who fears serious heart disease was referred to the mental health center by a cardiologist after extensive diagnostic evaluation showed no physical illness. The patient says, "I have tightness in my chest and my heart misses beats. I'm frequently absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Antisocial personality disorder c. Simple somatic symptom disorder d. Prominent health anxiety (hypochondriasis)

ANS: D Prominent health anxiety (hypochondriasis) involves a preoccupation with fears of having a serious disease, even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Simple somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others.

1. A physical therapist recently convicted of multiple counts of Medicare fraud says to a nurse, "Sure I overbilled. Why not? Everyone takes advantage of the government. They have so many rules - no one can follow them." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not exhibit anxiety, remorse, or guilt about the act. The patient's remarks cannot be assessed as shameful. Lack of trust or concern that others are determined to cause harm is not evident.

16. Which statement made by a patient with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." 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."

ANS: D Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

26. A patient with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." The nurse should help the patient by: a. encouraging meditation. b. administering an anxiolytic medication. c. helping the patient visualize a pleasant scene. d. helping the patient focus on the here and now.

ANS: D Talking with someone who can help the patient focus on reality allows the patient to interrupt the stimulus to dissociate. The incorrect options foster detachment.

16. For a patient with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by: a. functioning independently." b. verbalizing feelings of safety." c. regularly attending diversional activities." d. describing previously forgotten experiences."

ANS: D The ability to recall previously repressed or dissociated material is an indication that the patient is integrating identity and memory. A patient may verbalize feeling safe but may be disoriented and have memory deficits. A patient may be able to function independently on a basic level without being able to remember significant information. Attending activities is possible without being able to remember antecedent events.

13. The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratification to an appropriate time. d. little time elapsed between thought and action.

ANS: D The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

23. An essential difference between somatic system disorders and dissociative disorders is: a. Somatic system disorders are under voluntary control, whereas dissociative disorders are unconscious and automatic. b. Dissociative disorders are precipitated by psychologic factors, whereas somatic system disorders are related to stress. c. Dissociative disorders are individually determined and related to childhood sexual abuse, whereas somatic system disorders are culture bound. d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychologic stress through somatic symptoms.

ANS: D The key is the only fully accurate statement. Somatic system disorders are not under voluntary control and are not culture bound.

7. A nurse assessing a patient with a somatic system disorder is most likely to note that the patient: a. Readily sees a relationship between symptoms and interpersonal conflicts. b. Rarely derives personal benefit from the symptoms. c. Has little difficulty communicating emotional needs. d. Has altered comfort and activity needs.

ANS: D The patient frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain). In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic system disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others.

8. A patient's spouse filed charges of battery. The patient says, "I'm sorry for what I did. I need psychiatric help." The patient has a long history of acting-out behaviors and several arrests. Which statement by the patient suggests an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I'm tired of being nagged. My spouse deserves the beating."

ANS: D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.

18. For which behavior would limit setting be most essential? The patient: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

ANS: D This option is an example of a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other patients is at risk. Limit setting may be occasionally used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities. Rather, the need to develop trust is central to patient compliance.

A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a.The nurse interacts with the patient in a protective fashion. b.The nurse's comments to the patient are compassionate and nonjudgmental. c.The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d.The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS:A The nurse interacts with the patient in a protective fashion. In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parent's role. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referring a patient to a self-help group is an appropriate intervention.

A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a.Peripheral edema b.Parotid swelling c.Constipation d.Hypotension e.Dental caries f.Lanugo

ANS:A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia. See relationship to audience response question.

One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from: a.150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C pulse, 38 beats/min blood pressure 60/40 mm Hg b.120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C pulse, 50 beats/min blood pressure 70/50 mm Hg c.110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C pulse, 60 beats/min blood pressure 80/66 mm Hg d.90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C pulse, 62 beats/min blood pressure 74/48 mm Hg

ANS:A. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C pulse, 38 beats/min blood pressure 60/40 mm Hg Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

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.

ANS:A. Assist the patient to identify triggers to binge eating. For most patients with bulimia nervosa, certain situations trigger the urge to binge purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and 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? a."I am fat and ugly." b."What I think about myself is my business." c."I'm grossly underweight, but that's what I want." d."I'm a few pounds overweight, but I can live with it."

ANS:A. I am fat and ugly. Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell people perceptions of self. The patient with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.

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.

ANS:A. assess lung sounds and extremities Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a.now weighs 196 pounds. b.says, "I am using contraceptives." c.says, "I feel full after eating a small meal." d.reports problems with dry mouth and constipation.

ANS:A. now weighs 196 pounds. Lorcaserin is designed to make people feel full after eating smaller meals by activating a serotonin 2c receptor in the brain and blocking appetite signals. According to the FDA, this drug should be stopped if a patient does not have 5% weight loss after 12 weeks of use. If the patient now weighs 196 pounds, the medication has not been effective. The distracters indicate patient learning was effective and expected side effects of this medication.

Physical assessment of a patient diagnosed with bulimia often reveals: a.prominent parotid glands. b.peripheral edema. c.thin, brittle hair. d.25% underweight

ANS:A. prominent parotid glands Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

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.

ANS:B. Observe for adverse effects of refeeding. The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relate to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention.

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 compliance with treatment. 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.

ANS:B. Patient involvement in decision making increases sense of control and promotes compliance with treatment. A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a.Carefree flexibility b.Rigidity, perfectionism c.Open displays of emotion d.High spirits and optimism

ANS:B. Rigidity, perfectionism Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.

An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient: a.to eat a small meal after purging. b.not to skip meals or restrict food. c.to increase oral intake after 4 PM daily. d.the value of reading journal entries aloud to others.

ANS:B. not to skip meals or restrict food. One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private.

A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a.Flexible mealtimes b.Unscheduled weight checks c.Adherence to a selected menu d.Observation during and after meals e.Monitoring during bathroom trips f.Privileges correlated with emotional expression

ANS:C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patient's eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe patients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

CH 14 Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a.Binge eating b.Bulimia nervosa c.Anorexia nervosa d.Eating disorder not otherwise specified

ANS:C. Anorexia nervosa Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese. See relationship to audience response question.

As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a.Amenorrhea b.Alopecia c.Lanugo d.Stupor

ANS:C. Lanugo The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: 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?"

ANS:C. What do you eat in a typical day?" Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a.frequently smears feces on clothing and toys. b.experiences frequent nocturnal episodes of bedwetting. c.has accidents of defecation at kindergarten three times a week. d.has occasional episodes of voiding accidents at the day care center.

ANS:C. has accidents of defecation at kindergarten three times a week. Encopresis refers to unsuccessful bowel control. Bowel control is expected by age 5, so frequent involuntary defecation is associated with this diagnosis. Smearing feces is behavioral. Enuresis refers to the voiding of urine during the day (diurnal) or at night (nocturnal).

A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. 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.

ANS:C. how to recognize hypokalemia. Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a.maintaining patients' concentration and attention. b.shifting the patients' focus from food to psychotherapy. c.promoting processing of anxiety associated with eating. d.focusing on weight control mechanisms and food preparation.

ANS:C. promoting processing of anxiety associated with eating. Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.

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."

ANS:D. According to our agreement, no exercising is permitted until you have gained a specific amount of weight. A matter-of-fact statement that the nurse's perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a."What are your feelings about not eating foods 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 doesn't seem to solve your problems. You are thin now but still unhappy."

ANS:D. Being thin doesn't seem to solve your problems. You are thin now but still unhappy." The correct response is the only strategy that attempts to question the patient's distorted thinking.

The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a.Renal b.Endocrine c.Integumentary d.Cardiovascular

ANS:D. Cardiovascular Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patient's physiological integrity. The other body systems are not initially involved in the refeeding syndrome.

Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a.Powerlessness b.Ineffective coping c.Disturbed body image d.Imbalanced nutrition: less than body requirements

ANS:D. Imbalanced nutrition: less than body requirements The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? 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 reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

ANS:D. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia The patient's history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds height is 5 feet 4 inches. The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis. a.Anxiety related to fear of weight gain b.Disturbed body image related to weight loss c.Ineffective coping related to lack of conflict resolution skills d.Imbalanced nutrition: less than body requirements related to self-starvation

ANS:D. Imbalanced nutrition: less than body requirements related to self-starvation The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority.

Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a.Weight, muscle, and fat congruence with height, frame, age, and sex b.Calorie intake is within required parameters of treatment plan c.Weight reaches established normal range for the patient d.Patient expresses satisfaction with body appearance

ANS:D. Patient expresses satisfaction with body appearance Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a.Urine output 40 mL/hr b.Pulse rate 58 beats/min c.Serum potassium 3.4 mEq/L d.Systolic blood pressure 62 mm Hg

ANS:D. Systolic blood pressure 62 mm Hg Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hr. A potassium level of 3.4 mEq/L is within the normal range.

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.

ANS:D. gain 1 to 2 pounds Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome would not be on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a.appropriately express angry feelings. b.verbalize two positive things about self. c.verbalize the importance of eating a balanced diet. d.identify two alternative methods of coping with loneliness.

ANS:D. identify two alternative methods of coping with loneliness. The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

A nurse sitting with a client diagnosed with anorexia nervosa notices that the client has eaten 80% of lunch. The client asks the nurse "What do you like better, hamburgers or spaghetti?" Which is the best response by the nurse? A. I'm Italian, so I really enjoy a large plate of spaghetti B. I'll weigh you after your meal C. Let's focus on your continued improvement. You ate 80% of your lunch D. Why do you always talk about food? Let's talk about swimming

Answer :C It is important to offer support and positive reinforcement for improvements in eating behaviors. Because clients diagnosed with anorexia nervosa are obsessed with food, discussion of food can provide unintended positive reinforcement for negative behaviors. In this answer, the nurse is redirecting the client.

10. Which anorexia nervosa symptom in physical in nature? A. Dry, yellow skin B. Perfectionism C. Frequent weighing D. Preoccupation with food

Answer: A Dry yellow skin is a physical symptom of anorexia. This is due to the release of carotenes as fat stores are burned for energy.

A client diagnosed with an eating disorder has a nursing diagnosis of low self esteem. Which nursing intervention would address this client's problem? A. Offer independent decision making opportunities B. Review previously successful coping strategies C. Provide a quiet environment with decreased stimulation D. Allow the client to remain in a dependent role throughout treatment

Answer: A Offering independent decision making opportunities promotes feelings of control. Making decisions and dealing with the consequences of these decisions should increase independence and improve the client's self esteem. Reviewing previously successful coping strategies is an effective nursing intervention for clients experiencing altered coping, not low self esteem. Altered coping is a common problem for clients with eating disorders, but this diagnosis is not stated in the questions.

A client on an inpatient unit has been diagnosed with bulimia nervosa. The client states' "I'm going to the bathroom and will be back in a few minutes." Which nursing response is most appropriate? A. Thanks for checking in B. I will accompany you to the bathroom C. Let me know when you get back to the day room D. I'll stand outside your door to give you privacy.

Answer: B Any client suspected of self induced vomiting should be accompanied to the bathroom for the nurse to be able to deter this behavior.

A client with a long history of bulimia nervosa is seen in the emergency department. The client is seeing things that others do not, is restless, and has dry mucous membranes. Which is most likely the cause of this client's symptoms? A. Mood disorders, which often accompany the diagnosis of bulimia nervosa B. Nutritional deficits, which are characteristic of bulimia nervosa C. Vomiting, which may lead to dehydration and electrolyte imbalance D. Binging, which causes abdominal discomfort

Answer: C Purging behaviors, such as vomiting, may lead to dehydration and electrolyte imbalance. Hallucinations and restlessness are signs of electrolyte imbalance. Dry mucous membranes indicated dehydration. Nutritional deficits are characteristic of bulimia nervosa, but the client symptoms described in the question do not reflect a nutritional deficit.

Which outcome indicates that the client's problem of impaired body image has improved? A. The client has gained up to 80% of body weight for age and size B. The client is free of symptoms of malnutrition and dehydration C. The client has not attempted to self induce vomiting D. The client has acknowledged that perception of being fat is incorrect

Answer: D When clients can acknowledge that their perception of being fat is incorrect, they perceive a body image that is realistic and not distorted. This is evidence that the client's impaired body image has improved. The outcome of A indicated that the nursing diagnosis of imbalanced nutrition: less than body requirements, not impaired body image, has been resolved. Being free of B is an outcome that indicates the nursing diagnosis of imbalanced nutrition, less than body requirement, not impaired body image has been resolved. Not attempting self induced vomiting is an outcome that indicates that the nursing diagnosis of altered coping, not impaired body image, has been resolved. Not resorting to the maladaptive coping mechanism of self induced vomiting indicates improvement in the client's ability to cope effectively with stressors.