A nurse is caring for a patient diagnosed with anorexia nervosa. The patient has refused to eat during several meals. Which of the following is the most appropriate response by the nurse?

Correct Answer: D

Rationale: In the context of caring for a patient diagnosed with anorexia nervosa, the most appropriate response by the nurse is option D: Provide a non-judgmental and supportive environment to encourage the patient to eat. This option is the most suitable because it focuses on creating a safe and supportive space for the patient to feel comfortable and encouraged to make their own choices regarding eating. Option A, forcing the patient to eat, is not recommended as it can lead to feelings of distress, loss of autonomy, and potential resistance from the patient. Anorexia nervosa is a complex mental health disorder that involves underlying psychological factors, and coercion can exacerbate the situation. Option B, allowing the patient to make decisions without intervention, may not be appropriate in this scenario as individuals with anorexia nervosa may struggle with distorted thoughts and beliefs about food and eating. Providing support and guidance is crucial in helping the patient navigate these challenges. Option C, while well-intentioned, may not be as effective as option D. Simply explaining the importance of nourishment may not address the deeper emotional and psychological issues that contribute to the patient's refusal to eat. Creating a non-judgmental and supportive environment is key to building trust and facilitating positive changes in behavior. In an educational context, it is important for nurses to understand the complexities of eating disorders like anorexia nervosa and to approach care with empathy, sensitivity, and evidence-based practices. By focusing on building trust, providing support, and empowering the patient to make choices, nurses can play a crucial role in promoting recovery and well-being for individuals with eating disorders.

Correct Answer: D

Rationale: In this scenario, the child's varying recollections of the traumatic event indicate symptoms of dissociative amnesia, making option D the correct answer. Dissociative amnesia is a common response to trauma where individuals block out specific details or entire events as a coping mechanism to protect themselves from the emotional distress associated with the memory. Option A, depersonalization, involves feeling detached from oneself, which is not reflected in the child's situation. Option B, derealization, refers to a sense of unreality about one's surroundings, which is also not applicable in this case. Option C, hypervigilance, is a symptom commonly seen in post-traumatic stress disorder (PTSD) where individuals remain in a heightened state of alertness; however, it does not explain the child's varying recollections. Educationally, understanding trauma-related symptoms is crucial for healthcare professionals, especially psychiatric nurses, who work with individuals who have experienced traumatic events. Recognizing these symptoms can aid in providing appropriate care and support to help individuals cope and heal from their traumatic experiences effectively.

Correct Answer: B

Rationale: In this scenario, the most appropriate nursing diagnosis for the patient expressing feelings of worthlessness and hopelessness is option B) Hopelessness. Major depressive disorder often manifests with pervasive feelings of hopelessness, helplessness, and worthlessness. This nursing diagnosis accurately captures the patient's emotional state and is crucial for developing a comprehensive care plan to address the patient's mental health needs. Option A) Powerlessness refers to a lack of control over a situation or environment, which is not the primary concern in this case. The patient's statement reflects a deep sense of hopelessness rather than powerlessness. Option C) Risk for suicide may be a potential concern given the patient's expression of despair, but the immediate focus should be on addressing the underlying feelings of hopelessness before assessing suicide risk. It is important to acknowledge and validate the patient's emotions to establish trust and rapport before delving into risk assessment. Option D) Imbalanced nutrition: Less than body requirements is not the most appropriate nursing diagnosis in this context. While depression can affect appetite and eating habits, the patient's statement primarily reflects emotional distress rather than nutritional concerns. Educationally, understanding how to differentiate between nursing diagnoses is crucial for psychiatric nurses. By accurately identifying the patient's primary issue, nurses can tailor interventions to address the specific needs of individuals experiencing mental health challenges effectively. Effective assessment and diagnosis are fundamental aspects of providing holistic and patient-centered care in psychiatric nursing practice.

Correct Answer: A

Rationale: The most appropriate response in this scenario is option A: "I can see that you're feeling fearful about the government." This response demonstrates therapeutic communication by acknowledging the patient's feelings without dismissing or validating the delusion. It shows empathy and understanding, which can help in building trust and a therapeutic relationship with the patient. Option B, stating that "That's not true. No one is monitoring your thoughts," is incorrect as it directly denies the patient's belief, which can lead to further distress, lack of trust, and resistance to further communication. Option C, "Let's talk about why you believe the government is watching you," is a good response as it encourages exploration of the patient's thoughts and feelings. However, in this case, the patient's belief is a delusion, so diving deeper into the content of the delusion may not be as helpful at this moment. Option D, "You should try not to think about these things and focus on something else," is inappropriate as it dismisses the patient's experience and does not address the underlying issue. In an educational context, it's crucial for psychiatric nurses to understand the principles of therapeutic communication when working with patients experiencing delusions or hallucinations. Acknowledging the patient's feelings, maintaining empathy, and avoiding arguments or direct confrontation are key skills in effectively engaging with individuals with schizophrenia. Encouraging open dialogue, building trust, and validating emotions are essential components of providing holistic care in psychiatric nursing practice.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Patient will participate in one group activity per day. This outcome is the most appropriate because it is specific, measurable, achievable, and relevant to the nursing diagnosis of impaired social interaction. By setting a goal of participating in one group activity per day, the patient can gradually work on overcoming feelings of shyness and developing social skills. This outcome also allows for progress to be tracked and evaluated effectively. Option A) Patient will express satisfaction with social interactions is not the best choice because it focuses on the patient's feelings of satisfaction rather than tangible behavior change. Option B) Patient will independently seek out social interactions may be too challenging for a patient who is currently struggling with feelings of shyness. Option C) Patient will cooperate with group activities is vague and does not address the patient's need to actively engage in social interactions. From an educational standpoint, it is important to select outcomes that are realistic, measurable, and directly address the underlying nursing diagnosis. By choosing a specific and achievable goal like participating in one group activity per day, nurses can effectively guide patients towards improving their social interactions and overall well-being. Setting clear outcomes also helps in monitoring progress and adjusting interventions as needed to support the patient effectively.