A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.

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Question 1 of 5

A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.

Correct Answer: A

Rationale: Rationale: Option A is correct because replacing personal clothing with matching gym clothes simplifies dressing, reducing confusion for a patient with Alzheimer's. This intervention promotes independence and minimizes frustration. Labeling clothing (Option B) may help in identifying items but does not address the deficit. Clothing with elastic waistbands and closures (Option C) may be helpful but does not directly address the deficit. "None of the above" (Option D) is incorrect as Option A is an appropriate intervention.

Question 2 of 5

What is the most effective intervention to address the disturbed body image in patients with anorexia nervosa?

Correct Answer: B

Rationale: The correct answer is B because psychotherapy helps address the underlying psychological factors contributing to the disturbed body image in anorexia nervosa. Specifically, cognitive-behavioral therapy can challenge distorted thoughts about body image. Self-care routines (A) may not directly address the root cause. Group activities (C) may not target individual concerns effectively. Supporting meal selection (D) does not address the psychological aspect of body image distortion. In summary, psychotherapy is crucial in addressing the complex psychological issues associated with body image in anorexia nervosa.

Question 3 of 5

What is the most important aspect of nursing care for patients with anorexia nervosa during refeeding?

Correct Answer: B

Rationale: The correct answer is B: Start with small, manageable portions and gradually increase caloric intake. This approach is essential because refeeding syndrome can occur in patients with anorexia nervosa, where rapid refeeding can lead to severe electrolyte imbalances and potentially life-threatening complications. Starting with small portions helps to prevent this syndrome by allowing the body to gradually adjust to increased caloric intake. Additionally, it helps in preventing overwhelming the patient with large amounts of food, which can trigger anxiety and resistance to eating. Incorrect choices: A: Refeed the patient with high-calorie foods quickly to gain weight - This can lead to refeeding syndrome and is not a safe approach. C: Restrict food choices to healthy foods only - Restricting food choices can exacerbate disordered eating behaviors and does not address the need for gradual refeeding. D: Encourage the patient to take food supplements in addition to meals - While supplements can be helpful, they should not be a primary focus over balanced

Question 4 of 5

A nurse is working with a patient with bulimia nervosa. Which outcome would indicate successful intervention?

Correct Answer: A

Rationale: The correct answer is A because it indicates successful intervention in bulimia nervosa by demonstrating healthy eating behavior without purging. This outcome reflects improved control over binge-purge cycles and supports physical health. Choices B and D show progress but do not directly address the core issue of purging behavior. Choice C, losing weight, can be a misleading indicator and may not necessarily reflect improved psychological and behavioral outcomes associated with recovery from bulimia nervosa.

Question 5 of 5

A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority nursing diagnosis for this client is:

Correct Answer: B

Rationale: The correct answer is B: Risk for self-mutilation. This is the priority nursing diagnosis because the client is displaying behaviors such as self-injury due to difficulty tolerating angry feelings. Self-mutilation poses an immediate risk to the client's safety and requires immediate intervention. The other choices are incorrect because anxiety (A) is a common symptom of borderline personality disorder but not the priority in this case. Risk for other-directed violence (C) is not indicated as the client is primarily harming themselves. Ineffective coping (D) is a broad diagnosis that does not address the immediate risk of self-mutilation.

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