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.

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.

Correct Answer: B

Rationale: The correct answer is B. Tube feedings until the client eats 90% of all meals for 1 day. This intervention is appropriate for a client with anorexia nervosa who is refusing to eat. Tube feedings ensure adequate nutrition while also encouraging the client to resume eating orally. It is a gradual approach that aims to transition the client back to regular eating habits. Explanation for why other choices are incorrect: A: IV infusions are not the first-line intervention for a client with anorexia nervosa refusing to eat. This choice does not address the underlying issue of the client's refusal to eat. C: Placing the client on suicide precautions and one-to-one observation is not indicated solely based on refusal to eat. This choice does not address the nutritional needs of the client. D: Limiting peer group visitors for 2 weeks does not address the client's refusal to eat and is not a relevant intervention in this situation.

Correct Answer: B

Rationale: The correct answer is B: Bulimia. Individuals with bulimia nervosa typically have a normal or slightly above average body weight due to the cycle of binge eating and purging behaviors. This is because they consume large amounts of food during binges but then engage in compensatory behaviors such as vomiting or excessive exercise to prevent weight gain. In contrast, choices A (Pica) and D (Anorexia nervosa) are associated with low body weight. Choice C (Obesity) is characterized by excess body weight. Bulimia is the only disorder in the list where individuals can have a normal or slightly above average body weight due to the nature of their eating behaviors.

Correct Answer: C

Rationale: Step 1: Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted body image. Step 2: Patients often use strict control over food intake as a way to cope with underlying emotional issues. Step 3: Maintaining a sense of control is crucial in managing anorexia nervosa as it addresses the core psychological aspects driving the disorder. Step 4: Managing weight gain (A) is not the primary focus as patients may resist gaining weight due to their fear. Step 5: Controlling personal stressors (B) may be important but does not address the underlying issue of control related to food and body. Step 6: Avoiding social interactions (D) does not address the core psychological need for control and can further isolate the patient.