Which intervention would best address the nursing diagnosis of Imbalanced nutrition for elderly patients in stages 2 to 3 of Alzheimer's disease?

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Question 1 of 5

Which intervention would best address the nursing diagnosis of Imbalanced nutrition for elderly patients in stages 2 to 3 of Alzheimer's disease?

Correct Answer: B

Rationale: The correct answer is B: Offer finger foods the patient can take away from the table. This intervention is best suited for elderly patients in stages 2 to 3 of Alzheimer's disease as it promotes independent eating, encourages increased food intake, and addresses potential behavioral issues related to Alzheimer's. By offering finger foods that the patient can take away from the table, it allows for easier access to food, enhances the patient's ability to feed themselves, and reduces frustration or confusion that may arise during meal times. This approach supports the patient's autonomy and dignity while also addressing the nursing diagnosis of Imbalanced nutrition. Choice A is incorrect because monitoring bowel movements does not directly address the nutritional needs of the patient. Choice C focuses more on fluid balance rather than nutrition intake. Choice D is incorrect as providing protein-dense foods does not specifically target the challenges faced by elderly patients with Alzheimer's disease in stages 2 to 3.

Question 2 of 5

A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa?

Correct Answer: A

Rationale: The correct answer is A because the response indicates a distorted body image, a common characteristic of anorexia nervosa. Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted perception of body image, leading individuals to see themselves as overweight despite being underweight. In this case, the patient's response of "I'm fat and ugly" demonstrates a negative perception of their weight and appearance, which aligns with the distorted body image seen in anorexia nervosa. Choices B, C, and D are incorrect: B: "What I think about myself is my business" - This response does not indicate a distorted body image or negative perception of weight and appearance, which are key features of anorexia nervosa. C: "I'm grossly underweight, but I cover it well" - While this response acknowledges being underweight, it does not reflect the distorted body image commonly seen in anorexia nervosa. D: "I'm a

Question 3 of 5

A 14-year-old client on the eating disorders unit refuses to eat her meals and says to the nurse on the unit, 'You can't make me eat! There is nothing wrong with me.' The nurse will assess this as use of which defense mechanism?

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.

Question 4 of 5

A client with anorexia nervosa has refused meal trays and supplemental feedings for 3 days following admission to the general hospital. The nurse can anticipate that intervention will include:

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.

Question 5 of 5

Which disorder is associated with persons with a body weight that is normal or even slightly above average?

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.

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