A nurse is reviewing assessment findings for a 9-year-old child whose family home was destroyed in a wildfire. The nurse should identify that which of the following behaviors is related to the traumatic experience?

Correct Answer: C

Rationale: In this scenario, option C, "The child is found making small fires in the backyard," is related to the traumatic experience of the family home being destroyed in a wildfire. This behavior suggests a maladaptive coping mechanism where the child is reenacting or processing the traumatic event through play, potentially indicating unresolved trauma and distress. Option A, "The child insists on having their own way when playing with friends," and option B, "The child is rude to their siblings when things do not go their way," are more indicative of typical behavioral issues in children and do not directly relate to the trauma experienced by the child. Option D, "The child cries because they are the smallest child in their class," does not align with the traumatic event of a wildfire destroying the family home. This behavior may stem from issues related to self-esteem or social comparison but is not specifically linked to the traumatic experience described. In an educational context, understanding how children manifest trauma through their behavior is crucial for nurses and healthcare professionals to provide appropriate support and interventions. Recognizing these signs can help in early identification and intervention to address the underlying emotional needs of children who have experienced traumatic events.

Correct Answer: C

Rationale: The most appropriate nursing diagnosis for a patient diagnosed with bulimia nervosa who says, 'I can't stop eating even when I feel full' is option C: Ineffective coping related to lack of emotional regulation. In bulimia nervosa, individuals often engage in episodes of binge eating followed by compensatory behaviors like purging or fasting. The patient's statement indicates a lack of effective coping mechanisms to manage emotional triggers that lead to overeating even when full. This points to the core issue of inadequate coping skills in response to emotional distress, making option C the most suitable diagnosis. Option A (Imbalanced nutrition: Less than body requirements) may not be the best choice as the patient's statement does not directly indicate a deficiency in food intake, but rather a struggle with stopping eating once full. Option B (Disturbed body image related to distorted perception of self) is less appropriate because the patient's statement does not directly address body image concerns but rather focuses on the inability to control eating behaviors. Option D (Risk for self-directed violence related to impulsive behavior) is not the most suitable diagnosis based on the patient's statement. While individuals with bulimia nervosa may engage in harmful behaviors, the statement provided does not specifically suggest a risk for self-directed violence at this moment. Educationally, understanding the rationale behind selecting the most appropriate nursing diagnosis is crucial for nurses to provide effective care tailored to the patient's needs. By accurately identifying the underlying issue of ineffective coping in this case, nurses can develop targeted interventions to support the patient in developing healthier coping strategies to manage their eating behaviors and emotional challenges.

Correct Answer: D

Rationale: In the context of the nursing process, the implementation phase involves putting the care plan into action through carrying out interventions and coordinating care (option D). This is the correct answer because it is during this phase that nurses directly provide the planned interventions to help the patient achieve the desired outcomes. By implementing the planned interventions effectively, nurses contribute to promoting patient health and well-being. Option A, participating in mutual identification of patient outcomes, is associated with the planning phase where goals are set in collaboration with the patient and the healthcare team. Option B, gathering accurate and sufficient patient-centered data, pertains to the assessment phase where data is collected to inform the care plan. Option C, comparing patient responses and expected outcomes, is part of the evaluation phase where the effectiveness of interventions is assessed. Understanding the distinct roles of each phase of the nursing process is crucial for nurses to provide comprehensive and effective care. By correctly identifying the activities associated with each phase, nurses can ensure a systematic and holistic approach to patient care, leading to improved patient outcomes and quality of care delivery.

Correct Answer: B

Rationale: The most appropriate response by the nurse in this scenario is option B: "It sounds like you're feeling very concerned about your body image." This response demonstrates empathy and active listening, acknowledging the patient's feelings without judgment. It opens up the opportunity for the patient to express their emotions and concerns further, fostering a therapeutic nurse-patient relationship. Option A is incorrect because it dismisses the patient's feelings and can be perceived as invalidating. It does not address the underlying issue of body image distortion in anorexia nervosa. Option C is inappropriate as it is directive and does not consider the complexity of the patient's psychological condition. Option D is also not the best response as it focuses solely on the physical aspect of weight gain without addressing the patient's emotional distress. In an educational context, it is essential for nurses to develop strong communication skills to effectively support patients with mental health disorders like anorexia nervosa. By responding empathetically and non-judgmentally, nurses can create a safe space for patients to express their thoughts and feelings, which is crucial for building trust and promoting positive health outcomes.

Correct Answer: B

Rationale: In this scenario, option B is the most appropriate intervention for the nurse to implement. This option focuses on offering nonjudgmental support and exploring the patient's feelings about their eating behaviors. This approach is crucial in building trust and establishing a therapeutic relationship with the patient. By actively listening and empathizing with the patient, the nurse can help the patient feel understood and supported, which is essential in addressing the underlying issues contributing to their bulimia nervosa. Options A, C, and D are incorrect for several reasons. Option A, encouraging the patient to restrict their food intake, can exacerbate the patient's feelings of lack of control and may reinforce disordered eating behaviors. Option C, telling the patient to stop purging and eating excessively, is too directive and ignores the complex psychological factors contributing to the patient's condition. Option D, focusing on improving body image, may not address the root causes of the patient's bulimia nervosa. Educationally, it is important for nurses to understand the principles of therapeutic communication and person-centered care when working with patients with eating disorders. Building a supportive and nonjudgmental environment is key to fostering trust and promoting open communication, which are essential for effective assessment and intervention in these cases. By prioritizing empathy and active listening, nurses can better support patients in their recovery journey.