A nurse is assessing a patient with anorexia nervosa. Which of the following findings would be a priority for intervention?

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Question 1 of 5

A nurse is assessing a patient with anorexia nervosa. Which of the following findings would be a priority for intervention?

Correct Answer: C

Rationale: The correct answer is C: Body image disturbance and self-imposed starvation. This is a priority because it directly addresses the core issues of anorexia nervosa and poses immediate risks to the patient's health. Body image disturbance contributes to the patient's self-imposed starvation, which can lead to severe malnutrition and other serious complications. Addressing this issue is crucial for the patient's well-being. A: Weight loss of 2 pounds over the past week is concerning but may not be an immediate priority compared to addressing the underlying psychological issues. B: Denial of the need for nutrition rehabilitation is important to address but may not pose an immediate threat to the patient's health compared to self-imposed starvation. D: Refusal to participate in social activities may be a consequence of anorexia nervosa but does not directly address the urgent need to address body image disturbance and self-imposed starvation.

Question 2 of 5

Which intervention would best address the nursing diagnosis of Imbalanced nutrition for elderly patients in stages 2 to 3 of Alzheimer's disease?

Correct Answer: B

Rationale: The correct answer is B: Offer finger foods the patient can take away from the table. This intervention is best suited for elderly patients in stages 2 to 3 of Alzheimer's disease as it promotes independent eating, encourages increased food intake, and addresses potential behavioral issues related to Alzheimer's. By offering finger foods that the patient can take away from the table, it allows for easier access to food, enhances the patient's ability to feed themselves, and reduces frustration or confusion that may arise during meal times. This approach supports the patient's autonomy and dignity while also addressing the nursing diagnosis of Imbalanced nutrition. Choice A is incorrect because monitoring bowel movements does not directly address the nutritional needs of the patient. Choice C focuses more on fluid balance rather than nutrition intake. Choice D is incorrect as providing protein-dense foods does not specifically target the challenges faced by elderly patients with Alzheimer's disease in stages 2 to 3.

Question 3 of 5

A nurse is caring for a patient who is confused, disoriented in all three spheres, and experiencing visual hallucinations. While preparing to provide personal care, the nurse should:

Correct Answer: D

Rationale: The correct answer is D because explaining to the patient what will happen during care is essential to provide a sense of orientation and reduce anxiety in a confused patient. This approach helps the patient understand the situation and feel more in control, which can decrease agitation. Choice A is incorrect as the patient's memory deficit may lead to further confusion. Choice B is incorrect as minimal communication may not address the patient's needs. Choice C is incorrect as physical touch without explanation may escalate the patient's hallucinations.

Question 4 of 5

A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa?

Correct Answer: A

Rationale: The correct answer is A because the response indicates a distorted body image, a common characteristic of anorexia nervosa. Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted perception of body image, leading individuals to see themselves as overweight despite being underweight. In this case, the patient's response of "I'm fat and ugly" demonstrates a negative perception of their weight and appearance, which aligns with the distorted body image seen in anorexia nervosa. Choices B, C, and D are incorrect: B: "What I think about myself is my business" - This response does not indicate a distorted body image or negative perception of weight and appearance, which are key features of anorexia nervosa. C: "I'm grossly underweight, but I cover it well" - While this response acknowledges being underweight, it does not reflect the distorted body image commonly seen in anorexia nervosa. D: "I'm a

Question 5 of 5

A 14-year-old client on the eating disorders unit refuses to eat her meals and says to the nurse on the unit, 'You can't make me eat! There is nothing wrong with me.' The nurse will assess this as use of which defense mechanism?

Correct Answer: D

Rationale: The correct answer is D: Denial. Denial is a defense mechanism where an individual refuses to acknowledge reality to avoid discomfort. In this scenario, the client is denying the seriousness of their situation by refusing to eat and claiming there is nothing wrong. Repression (A) involves unconsciously blocking out unpleasant thoughts or feelings. Rationalization (B) is creating logical explanations to justify behavior. Sublimation (C) is redirecting negative impulses into positive behaviors. In this case, denial is the most fitting defense mechanism as the client is refusing to accept the reality of their eating disorder.

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