Which of the following is a priority nursing intervention for a patient with anorexia nervosa during the refeeding process?

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Question 1 of 5

Which of the following is a priority nursing intervention for a patient with anorexia nervosa during the refeeding process?

Correct Answer: B

Rationale: The correct answer is B because monitoring vital signs and electrolyte levels is crucial during the refeeding process to prevent refeeding syndrome, a potentially life-threatening complication. This intervention ensures early detection of any electrolyte imbalances or cardiac complications that may arise as the body readjusts to increased food intake. Encouraging physical activity (A) can be harmful due to the patient's compromised state. Offering high-calorie snacks (C) may lead to rapid weight gain and increase the risk of refeeding syndrome. Focusing on body image concerns (D) is important but should not take precedence over addressing the patient's immediate medical needs.

Question 2 of 5

A patient remanded by the court after his wife had him jailed for battery told the judge how sorry he was and suggested he needed psychiatric help. His history reveals acting-out behaviors as an adolescent and several adult arrests. The nurse interviews him about his relationship with his wife. Which statement by the patient is most consistent with a diagnosis of antisocial personality disorder?

Correct Answer: D

Rationale: The correct answer is D because it demonstrates a lack of remorse, empathy, and justification for violent behavior, which are key characteristics of antisocial personality disorder. The statement indicates a pattern of blaming others for his actions and a sense of entitlement to use violence as a means of control. Choice A is incorrect because it shows acknowledgment of past mistakes and a willingness to learn from them, which is not typical of individuals with antisocial personality disorder. Choice B is incorrect as it reflects genuine regret and concern for the impact of his actions, which is inconsistent with the disorder. Choice C is incorrect because it implies an ability to control his temper, whereas individuals with antisocial personality disorder often struggle with impulsivity and aggression.

Question 3 of 5

Which nursing diagnosis would be appropriate for a patient with Alzheimer disease?

Correct Answer: D

Rationale: The correct answer is D: Disturbed thought processes related to irreversible brain disorder. This nursing diagnosis is appropriate for a patient with Alzheimer's disease because Alzheimer's is characterized by cognitive decline and disturbances in thought processes due to irreversible brain changes. Disorientation related to hyperthermia (A) is not directly associated with Alzheimer's. Anxiety related to dementia (B) is a symptom of Alzheimer's, not a nursing diagnosis. Disturbed sensory perception related to alcohol abuse (C) is not relevant to a patient with Alzheimer's disease. It is crucial to focus on the specific symptoms and characteristics of Alzheimer's disease when selecting the appropriate nursing diagnosis.

Question 4 of 5

An elderly patient with dementia paces the hallway and often engages in wandering. The nurse documents that the patient is exhibiting which type of behavior that is characteristic of dementia?

Correct Answer: D

Rationale: The correct answer is D: Nonaggressive psychomotor behavior. In dementia, wandering and pacing are common behaviors due to cognitive impairment. Nonaggressive behavior refers to actions that do not involve harm or aggression towards others. The patient's behavior is voluntary and purposeless, indicating psychomotor involvement. Choices A, B, and C do not accurately describe the behavior exhibited by the patient with dementia. Passive behavior implies lack of engagement, functionally impaired behavior suggests difficulty performing activities of daily living, and involuntary psychomotor behavior implies actions beyond the patient's control, which are not the case in this scenario.

Question 5 of 5

A client being treated for anorexia nervosa is 5 feet 10 inches tall and weighs 100 pounds. The client believes she is overweight. On the days the client is scheduled to be weighed, the nurse should be prepared for the client to:

Correct Answer: B

Rationale: Correct Answer: B - Dress in several layers of clothing. Rationale: An individual with anorexia nervosa often engages in behaviors to manipulate their weight, such as wearing heavy clothing to increase their weight on the scale. This behavior is a result of distorted body image and fear of gaining weight. By dressing in several layers of clothing, the client may attempt to influence the scale reading to align with their perceived body image. Summary of other choices: A: Eagerly asking for information about her present weight is unlikely as individuals with anorexia nervosa typically avoid discussions or confrontations related to their weight. C: Suggesting that the scale numbers be hidden is not as likely as the client may want to see the numbers to validate their belief of being overweight. D: Reminding the nurse that she is ready to be weighed may occur, but it does not address the behavior of dressing in layers to manipulate weight.

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