A 72-year-old widow has just returned home after 2 weeks in the hospital after a fall. She lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the visiting nurse stopped by 2 days after discharge, he found the woman confused and disoriented, with an unsteady gait. The patient asks him who he is and why he is there. The nurse correctly deduces that the most likely cause for the changes seen in the patient is:

Correct Answer: A

Rationale: The correct answer is A: Delirium. The patient's sudden onset of confusion, disorientation, and unsteady gait after discharge from the hospital suggests delirium. Delirium is an acute change in mental status with fluctuating symptoms, often caused by underlying medical conditions, medications (such as diazepam), or environmental factors. In this case, the recent hospitalization, multiple medications, and potential stressors like living alone and recent fall increase the risk for delirium. Incorrect choices: B: Dementia is a chronic, progressive condition characterized by memory loss and cognitive decline. The sudden onset of symptoms in this case is not consistent with dementia. C: Drug toxicity could be a possibility given the patient's medication list, but delirium is a more likely explanation due to the acute onset of symptoms post-hospitalization. D: None of the above is incorrect because delirium is the most likely cause based on the patient's presentation and risk factors.

Correct Answer: A

Rationale: The correct answer is A: Vomiting. In bulimia, vomiting is the most common method of purging after binge eating to control weight. Monitoring for signs of vomiting, such as frequent trips to the bathroom after meals or presence of swollen salivary glands, is crucial. Starvation (B) is not a method of purging in bulimia but rather a consequence of restriction in anorexia nervosa. Excessive enema use (C) is not a common method of purging in bulimia and can be harmful. Therefore, the correct choice is A as it aligns with the typical behavior of individuals with bulimia.

Correct Answer: C

Rationale: The correct answer is C: Encourage the patient to avoid purging after meals. This is the most appropriate action because it addresses the harmful purging behavior associated with bulimia nervosa. By encouraging the patient to avoid purging, the nurse can help prevent serious health consequences such as electrolyte imbalances and damage to the esophagus. Option A is incorrect because assigning a strict dietary plan may exacerbate the patient's unhealthy relationship with food and contribute to feelings of guilt and shame. Option B is incorrect as monitoring for physical symptoms of starvation may not directly address the underlying issue of purging behavior. Option D is also incorrect as providing emotional support alone may not effectively address the harmful purging behavior.

Correct Answer: B

Rationale: The primary goal for a nurse treating a patient with anorexia nervosa is to restore the patient's nutritional balance and weight. This is because individuals with anorexia nervosa often have severe malnutrition and weight loss, which can lead to serious health complications. By focusing on restoring nutritional balance and weight, the nurse can help improve the patient's physical health and overall well-being. Encouraging the patient to achieve optimal body weight quickly (choice A) may not be realistic or safe, as rapid weight gain can have negative consequences. Involving the patient in daily exercise routines (choice C) may exacerbate the patient's compulsive behaviors around food and exercise. Encouraging the patient to undergo intensive psychotherapy (choice D) is important, but it is not the primary goal in the initial treatment of anorexia nervosa.

Correct Answer: C

Rationale: Step-by-step rationale for choice C (Impaired social interaction) being the correct answer: 1. Antisocial personality disorder is characterized by a lack of regard for others and a pattern of violating their rights. 2. Individuals with this disorder often have difficulty forming and maintaining healthy relationships. 3. Impaired social interaction reflects the challenges the individual faces in relating to others. 4. This nursing diagnosis would address the core issue of social dysfunction in individuals with antisocial personality disorder. Summary of why the other choices are incorrect: A. Risk for self-mutilation - Not typically associated with antisocial personality disorder, more common in other mental health conditions. B. Disturbed personal identity - Not a primary concern in antisocial personality disorder, which is more about behavior than identity. D. Social isolation - While individuals with antisocial personality disorder may isolate themselves, impaired social interaction is a more direct and specific issue to address in their care.