A patient diagnosed with bulimia nervosa is admitted for treatment. The patient is assessed to have a BMI of 17.5. What is the priority nursing intervention for this patient?

Correct Answer: D

Rationale: In this scenario, the priority nursing intervention for a patient diagnosed with bulimia nervosa and a low BMI of 17.5 is to assess the patient for signs of self-induced vomiting and purging behaviors (Option D). This intervention is crucial because individuals with bulimia nervosa often engage in these harmful behaviors to control their weight, leading to serious physical and psychological consequences. By identifying and addressing these behaviors promptly, nurses can prevent further health complications and provide appropriate interventions. Option A, monitoring the patient's nutritional intake and weight regularly, is important in the overall management of bulimia nervosa, but it is not the priority when the patient's BMI is critically low. Option B, encouraging the patient to discuss their eating habits openly, may be beneficial for building rapport and trust but does not address the immediate health risks associated with a low BMI. Option C, providing structured meal plans and counseling, is also essential in the long-term treatment of bulimia nervosa but does not address the urgent need to assess and intervene in self-induced purging behaviors. From an educational perspective, understanding the priority of interventions based on the patient's condition and prioritizing immediate health risks in psychiatric nursing is crucial. By focusing on the most critical aspect of care first, nurses can ensure patient safety and well-being in acute situations like this one. The rationale behind choosing the correct intervention should always be grounded in evidence-based practice and an understanding of the specific needs of patients with eating disorders.

Correct Answer: C

Rationale: In the context of psychiatric nursing, it is crucial to understand the effects of different herbal treatments on mental health conditions like depression. In this scenario, the correct answer is C) St. John's Wort. St. John's Wort is a well-known herbal remedy that has been used traditionally to alleviate symptoms of mild to moderate depression. It contains active compounds that are believed to have antidepressant properties by affecting neurotransmitters in the brain. Option A) Black cohosh is not typically used for depression but rather for menopausal symptoms and gynecological issues. Option B) Ginseng is more commonly associated with boosting energy and reducing stress rather than treating depression. Option D) Ginkgo is often used for improving memory and cognitive function, not specifically for depression. Educationally, understanding the effects of various herbal treatments on mental health conditions allows psychiatric nurses to have informed discussions with clients seeking alternative or complementary therapies. It highlights the importance of evidence-based practice in guiding treatment decisions and promoting holistic care for individuals with mental health challenges. By knowing the specific uses and effects of different herbal remedies, nurses can better support their clients in making informed choices about their mental health care.

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.