NUR 203 Study guide 18/27 EXAM
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
"According to our agreement, no exercising is permitted until you have gained a specific amount of weight."
A nurse named Darryl has been hired to work in a psychiatric intensive care unit. He has undergone training on recognizing escalating anger. Which statement indicates that he understands danger signs in regard to aggression?
"An obvious change in behavior is a risk factor for aggression."
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
"Being thin doesn't seem to solve your problems. You are thin now but still unhappy."
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
"I am fat and ugly!"
A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:
"I'd like to talk with you about how you're feeling right now."
A newly admitted male patient has a long history of aggressive behavior toward staff. Which statement by the nurse demonstrates the need for more information about the use of restraint?
"I'll call the primary provider and get an as needed (prn) seclusion/restraint order."
An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention
"My fingers are tingly."
Which example demonstrates aggresion
"You stole my seat, you better move."
A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say:
"You want to go home to prepare your husband's dinner?"
Which intervention(s) should the nurse implement when helping a patient expresses anger in an inappropriate manner? Select all that apply.
-Approach the patient in a calm, reassuring manner. -Provide suggestions regarding acceptable ways of communicating anger. -Set limits on the angry behavior that will be tolerated.
Anorexia Nervosa
-Chronic illness wax and wane -Restrict Intake or engage in binging/purging -Refuse to maintain minimally normal weight for height and express an intense fear of gaining weight
Bulimia Nervosa
-Engage in repeated episodes of binge eating followed by self induced vomiting -misuse of laxatives and/or diuredtics -fasting, excessive, exercise -significant disturbance in preception of body shape and weight
Anorexia Nervosa
-Intense fear of weight gain -Distorted body image -Restricted calories with significantly low BMI ---Subtypes: Restricting (no consistent bulimic features) Binge/eating/purging type (primarily restriction, some bulimic behaviors)
Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion Select all that apply.
-Patient behaviors associated with the incident -Intervention techniques used by the staff -Effects of environmental factors
Advanced Practice Interventions
-Psychotherapy >Individual therapy >Group therapy > Family therapy
Bulimia Nervosa
-Recurrent episodes of uncontrollable binging -Inappropriate compensatory behaviors: vomiting, laxatives, diuretics, or exercise -Self-image largely influenced by body image
Binge Eating
-Recurrent episodes of uncontrollable binging without compensatory behaviors -Binging episodes induce guilt, depression, embarrassment, or disgust
Rumination disorder
-Regurgitation with rechewing, reswallowing or spitting -No GI or medical reason -Not part of other mental illness or eating disorder
A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario Select all that apply.
-Stating the expectation that the patient will stay in control -Offering to provide the patient with medication to help -Speaking in a firm but calm voice
Binge Eating Disorder
-engage in repeated episodes of binge eating then experience significant distress -no compensatory behaviors-laxitives/vomiting -Can lead to obesity
Which neurotransmitters play a vital role in anger/aggression
-serotonin -dopamine -GABA
Anorexia signs and symptoms
-severely underweight -growth of fine downy hair lanugo on the face and back -cold -mottled skin -low BP -Low HR -low temp
Rumination disorder
-undigested food being returned to the mouth, rechewed, reswallowed or spit out -neglect pre-disposing factor
One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed The patient whose weight decreased from:
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
After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care
A wish for revenge
What are the physical findings to suspect in Bulimia
Abrasions and calluses on the knuckles
What would be a nursing diagnosis that reflects the problem?
Altered nutrition: less than body requirements r/t decreased intake
Anger
An emotional response to frustration of desires, threat to one's needs emotional or physical, or a challenge
Twenty-four-hour observation is a good choice for restraint in which of the following patients?
An inmate with suicidal ideation on hospice care
A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take Select all that apply.
Appoint a person to clear a path and open, close, or lock doors. Select the person who will communicate with the patient. Remove jewelry, glasses, and harmful items.
What is an intervention for how a patient with an eating disorder views their body?
Ask the patient to dray a picture of themselves as they see themselves now and then have them draw a picture of how they desire to be
The client is unable to control his anger with criticism, but could control anger before-What is the intervention?
Assisst the patient with a detailed exploration of how he reacts to criticism
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa
Assist the patient to identify triggers to binge eating.
An effective method of preventing escalation in an environment with violent offenders is to develop a level of trust through:
Brief, frequent, nonthreatening encounters
A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient
Continue the dressing change, saying, "This dressing change is needed so your wound will not get infected."
What is pica
Eating nonfood items after maturing past toddlerhood Not culturally sanctioned Not part of any other mental illness
John Patrick is a widower with four daughters. He has enjoyed a healthy relationship with all of them until they reached puberty. As each girl began to mature physically, he acted in an aggressive manner, beating her without provocation. John Patrick is most likely acting on:
Frustration of unhealthy desire
A patient with anorexia has short term outcome of what?
Gain 2lbs in a week
What is one way to assess the degree of stress with Anorexia Nervosa?
Has the menstural period stopped?
Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence
Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.
A patient has a history of impulsively acting out anger by striking others. Select the most appropriate intervention for avoiding similar incidents.
Help the patient identify incidents that trigger impulsive anger.
Which assessment finding presents the greatest risk for violent behavior directed at others
History of spousal abuse
What is the nursing diagnosis for binge eating disorders?
Hopelessness
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
Imbalanced nutrition: less than body requirements
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
Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
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.
Imbalanced nutrition: less than body requirements related to self-starvation
What is seclusion
Involuntary confinement alone in a room that the patient is physically prevented from leaving
A nurse has a new admission with a patient with anorexia-What is the priority intervention?
Monitor vital signs and labs to anticipate medical problems
Since purging and excessive exercise are not features of binge eating disorders, these patients often become what?
Obeses
Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight
Observe for adverse effects of refeeding.
What is the most appropriate intervention for purging behaviors with bulimia?
Observe the patient for 1 hour after the meals
What are behaviors of patients with anorexia
Obsessive rituals
Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention
Olanzapine (Zyprexa)
Feeding Disorders
PICA-persistent eating of substances such as dirt or paint of no nutritional value
Which scenario predicts the highest risk for directing violent behavior toward others
Paranoid delusions of being followed by alien monsters
What is the most appropriate intervention for the nurse with patients who have bulimia nervosa?
Patient education
Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor
Patient expresses satisfaction with body appearance
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
Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment.
What conditions are related to patients with binge-eating disorders
Patients report adhedonia and oversleeping
An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger
Periodically provide an update and progress report on the patient.
The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize
Practice and teamwork
A child has anger issues, the nurse must avoid what to remain therapeutic
Projecting his/her feelings on the patient
What medication is used to treat Bulimia nervosa and anorexia nervosa?
Prozac/Fluoxetine
Which example of behavior warrants seclusion?
Psychotic patient with increased suspiciousness and agitation/aggression toward others
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa
Rigidity, perfectionism
A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority
Risk for other-directed violence
For a unit that has a high acuity of seclusion/restraints-what would be an appropriate action for the staff?
Rotating the schedule of frequent breaks to reduce their stress
Which behavior best demonstrates aggression
Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.
Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization
Systolic blood pressure 62 mm Hg
A patient with a history of anger and impulsivity was hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolded nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem
Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia.
What are boundaries for families of a paitent with an eating disorder?
The family members of patients with anorexia become enmeshed
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
The nurse interacts with the patient in a protective fashion.
What is a poor outcome for patients with anorexia nervosa?
The patient actively resents or refuses treatment
A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action
The patient interpreted the UAP's behavior as potentially harmful.
What is the best response to a patient that states that she has lost 10lbs in 3 months and she thinks that she has anorexia?
The patient may be anorexic if weight loss leads to a maintance body weight less than 85% of the expected
Which documentation is the best for a patient placed in seclusion?
The response with the most descriptive, detailed, using a timeline-Painting a picture of events with documentation
What are the physical findings regarding a patient weight consistent with binge eating?
Usually normal or slightly above normal average weight
A 20-year-old woman who primarily restricts her eating has also resorted to purging when her family forces her to eat. As part of her treatment plan on a general psychiatric unit, the dietitian ordered specific meals for her. She became visibly distressed after eating one of these meals and requested permission to go to the bathroom alone because she had "embarrassing gas." The nurse agreed to stand away from the bathroom door if the patient agreed not to flush the toilet until the nurse was able to inspect the contents; however, the patient flushed the toilet. The treatment team concluded that she broke the contract with the nurse and was not able to adhere to her prescribed treatment without additional structure. The treatment team established a new goal that she gain 2 pounds and an intervention that she wait 30 minutes after every meal before she was allowed supervised bathroom breaks.
Vignette
A nursing assessment of a small group of three young women and one young man in a nutrition group finds that all the participants are very knowledgeable about the caloric value of common foods; as a group, they all avoid any "fatty" foods. The topic of fat-soluble vitamins and the consequences of vitamin deficiencies on the body was new information to all of the participants, and one of the young women started to cry, saying, "I had no idea I was doing that to my body." This show of emotion promoted a supportive interaction among the other group members as they shared their own stories of symptoms they could now identify as vitamin deficits.
Vignette
Alicia, a 17-year-old cheerleader, did not come to treatment for weight loss until she fainted at a football game. She insisted that she only needed to "get more energy, not get fat." When the nurse pointed out that Alicia's ribs were clearly visible and that her backbone looked like a skeleton, Alicia grinned and said, "Thank you."
Vignette
Becky, a 23-year-old patient with a 6-year history of bulimia nervosa, struggles with issues of self-esteem. She expresses much guilt about "letting her father down" in the past by drinking alcohol excessively and binge eating and purging. She is determined that this time she is not going to fail at treatment. After her initial success in stopping the disordered behaviors, she says defiantly, "I'm doing this for me." Becky usually experiences her behavior as either pleasing or disappointing to others, but she begins to realize that her feeling of self-worth is very much dependent on how others see her and that she needs to develop a better sense of herself.
Vignette
During the initial assessment, the nurse wonders if Brittany is actually in need of hospitalization on the eating-disorders unit. The nurse is struck by how well the patient appears, seeming healthy, well-dressed, and articulate. As Brittany continues to relate her history, she tells of restricting her intake all day until early evening, when she buys her food and begins to binge as she is shopping. She arrives home and immediately induces vomiting. For the remainder of the evening and into the early morning hours, she "zones out" while watching television and binge eating. Periodically, she goes to the bathroom to vomit. She does this about 15 times during the evening. The nurse admitting Brittany to the unit reminds her of the goals of the hospitalization, including interrupting the binge-purge cycle and normalizing eating. The nurse further explains to Brittany that she has the support of the eatingdisorder treatment team and the milieu of the unit to assist her toward recovery.
Vignette
Iris weighs 85% of her ideal body weight. She has a history of diuretic abuse, and she becomes edematous when she stops their use and enters treatment. The nurse informs Iris that the edema is related to the use of diuretics (and thus is transient) and that it will resolve after Iris begins to eat normally and discontinues the diuretics. Iris cannot tolerate the weight gain and the accompanying edema that occurs when she stops taking diuretics. She restarts the diuretics, perpetuating the cycle of fluid retention and the risk of kidney damage. The nurse empathizes with Iris's inability to tolerate the feelings of anxiety and dread she experiences because of her markedly swollen extremities.
Vignette
Mrs. Demi's daughter, Lila, has gained 40 pounds. Together they attend a family support group where the group leader asks how she regards her daughter now that she has been in treatment. Mrs. Demi replies, "She looks healthy." Her daughter responds with an angry, sullen look. She ultimately verbalizes that she interprets comments about her "healthy" appearance as "You look fat." The group leader points out that it is interesting that Lila equates "healthy" with "fat."
Vignette
A patient presents with a long history of bulimia with visual hallucinations, restlenssness, and dry mucous membranes-cause?
Vomiting=dehydration and electrolyte imbalance
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:
What do you eat in a typical day?
Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in:
a personality style that externalizes problems.
Which individuals are most at risk for displaying aggressive behavior? Select all that apply.
a. An adolescent embarrassed in front of friends. b. A young male who feels rejected by the social group. d. A middle-aged adult who feels that concerns are going unheard. e. A patient who was discovered telling a lie.
Which guidelines should direct nursing care when deescalating an angry patient? Select all that apply. a. Intervene as quickly as possible b. Identify the trigger for the anger c. Behave calmly and respectfully d. Recognize the patient's need for increased personal space e. Demands are agreed to as long as they won't result in harm to anyone
a. Intervene as quickly as possible b. Identify the trigger for the anger c. Behave calmly and respectfully d. Recognize the patient's need for increased personal space
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.
An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the dayroom. The nurse should enter the day room:
accompanied by 3 staff members and say, "Please come to your room so I can give you some medication that will help you regain control."
Aggression
action/behavior that results in verbal or physical attack
Which central nervous system structures are most associated with anger and aggression Select all that apply.
amygdala temporal lobe Prefrontal cortex
What observation of a patient with Schizophrenia is indicative of a patient's potential for violence?
an intense stare
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
anorexia nervosa
What is a restraint
any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should:
assess lung sounds and extremities.
Which comorbid condition would result in cautious use of a selective serotonin reuptake inhibitors for a patient with chronic aggression?
bipolar disorder
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
cardiovascular
Chronic obstructive pulmonary disease, spinal injury, seizure disorder, and pregnancy are conditions that:
contraindicate restraint and seclusion
What is necessary prior to interveneing with an adolescent projectiong anger on the nurse-the nurse should
encourage the adolescent to engage in introspection to examine how he/she reacts to others when they are angry
A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is:
exhibiting clues to potential aggression.
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:
gain 1 to 2 pounds.
A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to:
how to recognize hypokalemia.
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:
identify two alternative methods of coping with loneliness.
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
lanugo
A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the day room. While following the patient into the day room, the nurse should:
make sure there is adequate physical space between the nurse and patient.
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient:
not to skip meals or restrict food.
Violence
objectionable act that involves intentional use of force that could or does not result in injury of another person
An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient:
presented a clear and present danger to others.
Physical assessment of a patient diagnosed with bulimia often reveals:
prominent parotid glands.
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of:
promoting processing of anxiety associated with eating.
A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by:
saying to the patient, "This is a safe place."
Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence A history of:
substance abuse
compensatory actions
using laxatives and diuretics to lose weight
Avoidant/restrictive disorder
• Avoiding or restricting foods starting in childhood • Significantly low BMI • Dependent on enteral feeding or experiencing nutritional deficiencies • No distortion of body image • Not medically explained or part of any other mental illness
Encopresis
• Behavioral disorder in children who are developmentally older than age 4 • Involuntary or intentional inappropriate passing of feces • Occurs once a month for more than 3 months • Subtypes: With constipation and overflow incontinence or without constipation and overflow incontinence.
Enuresis
• Behavioral disorder in children who are developmentally older than age 5 • Involuntary or intentional voiding of urine into clothing or bed • Occurs twice a week for more than 3 months. • Subtypes: Nocturnal, diurnal, or nocturnal and diurnal.
