Question 1
Regular
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. She wears layered, loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Anorexia nervosa. The woman's significant weight loss, tiny food portions, amenorrhea, and avoidance of tight clothing indicate a restrictive behavior pattern typical of anorexia nervosa, reflecting an intense fear of gaining weight.
A: Binge-eating disorder. This diagnosis involves consuming large amounts of food in a short period, which does not align with her described behavior of tiny servings and weight loss.
C: Bulimia nervosa. This condition features cycles of binge eating followed by purging, which contradicts her consistent small portion sizes and absence of purging behaviors indicative of bulimia.
D: Pica. Pica involves compulsive eating of non-nutritive substances, which is unrelated to her symptoms of weight loss and amenorrhea, showing no evidence of unusual eating behaviors.
Correct Answer: B
Rationale: B: Anorexia nervosa. The woman's significant weight loss, tiny food portions, amenorrhea, and avoidance of tight clothing indicate a restrictive behavior pattern typical of anorexia nervosa, reflecting an intense fear of gaining weight.
A: Binge-eating disorder. This diagnosis involves consuming large amounts of food in a short period, which does not align with her described behavior of tiny servings and weight loss.
C: Bulimia nervosa. This condition features cycles of binge eating followed by purging, which contradicts her consistent small portion sizes and absence of purging behaviors indicative of bulimia.
D: Pica. Pica involves compulsive eating of non-nutritive substances, which is unrelated to her symptoms of weight loss and amenorrhea, showing no evidence of unusual eating behaviors.
Question 2
Regular
Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor?
Correct!
Incorrect
The correct answer is: D
Rationale
The patient expresses satisfaction with body appearance. This outcome indicator directly addresses the core issue of disturbed body image, focusing on the patient's perception and feelings about their body, which is essential in treating eating disorders.
A: Weight, muscle, and fat are congruent with height, frame, age, and sex. This option focuses on physical metrics rather than the patient's psychological perspective, which is crucial for addressing body image disturbances.
B: Calorie intake is within the required parameters of the treatment plan. Monitoring caloric intake emphasizes nutrition but neglects the emotional and psychological aspects of body image, which are vital for recovery.
C: Weight reaches the established normal range for the patient. While achieving a normal weight is important, it does not inherently reflect the patient's personal feelings and satisfaction regarding their body image.
Correct Answer: D
Rationale: The patient expresses satisfaction with body appearance. This outcome indicator directly addresses the core issue of disturbed body image, focusing on the patient's perception and feelings about their body, which is essential in treating eating disorders.
A: Weight, muscle, and fat are congruent with height, frame, age, and sex. This option focuses on physical metrics rather than the patient's psychological perspective, which is crucial for addressing body image disturbances.
B: Calorie intake is within the required parameters of the treatment plan. Monitoring caloric intake emphasizes nutrition but neglects the emotional and psychological aspects of body image, which are vital for recovery.
C: Weight reaches the established normal range for the patient. While achieving a normal weight is important, it does not inherently reflect the patient's personal feelings and satisfaction regarding their body image.
Question 3
Regular
A patient who was referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient's oral intake, the nurse should ask which assessment question?
Correct!
Incorrect
The correct answer is: C
Rationale
C: What do you eat in a typical day? This question directly evaluates the patient's dietary habits, enabling the nurse to understand the quantity and quality of food intake, which is crucial for assessing the severity of the eating disorder.
A: Do you often feel fat? While this question touches on body image, it fails to address specific dietary practices, which are essential for understanding the patient's nutritional intake.
B: Who plans the family meals? This inquiry focuses on the family dynamics rather than the patient's individual eating behavior, which is necessary to accurately assess their oral intake.
D: What do you think about your present weight? This question addresses the patient's perception but does not provide insight into their actual eating patterns or nutritional habits, which are vital for assessment.
Correct Answer: C
Rationale: C: What do you eat in a typical day? This question directly evaluates the patient's dietary habits, enabling the nurse to understand the quantity and quality of food intake, which is crucial for assessing the severity of the eating disorder.
A: Do you often feel fat? While this question touches on body image, it fails to address specific dietary practices, which are essential for understanding the patient's nutritional intake.
B: Who plans the family meals? This inquiry focuses on the family dynamics rather than the patient's individual eating behavior, which is necessary to accurately assess their oral intake.
D: What do you think about your present weight? This question addresses the patient's perception but does not provide insight into their actual eating patterns or nutritional habits, which are vital for assessment.
Question 4
Regular
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, 'Describe what you think about your present weight and how you look.' Which response by the patient is most consistent with the diagnosis?
Correct!
Incorrect
The correct answer is: A
Rationale
I am fat and ugly. This response aligns with anorexia nervosa, where individuals often have a distorted body image, perceiving themselves as overweight despite significant weight loss. Such negative self-assessment reflects their deep-seated body dissatisfaction and emotional struggles related to their eating disorder, emphasizing the severity of their condition and the need for comprehensive treatment.
B: What I think about myself is my business. This response indicates a level of detachment from self-awareness and may reflect defensiveness instead of the distorted self-image characteristic of anorexia nervosa.
C: I am grossly underweight, but that's what I want. Acceptance of being underweight contradicts the typical body image distortion seen in anorexia, where individuals usually deny their actual weight status and desire to lose more weight.
D: I am a few pounds overweight, but I can live with it. This statement reflects a misperception of body weight and suggests a lack of concern about their condition, which does not align with the intense body dissatisfaction found in anorexia nervosa.
Correct Answer: A
Rationale: I am fat and ugly. This response aligns with anorexia nervosa, where individuals often have a distorted body image, perceiving themselves as overweight despite significant weight loss. Such negative self-assessment reflects their deep-seated body dissatisfaction and emotional struggles related to their eating disorder, emphasizing the severity of their condition and the need for comprehensive treatment.
B: What I think about myself is my business. This response indicates a level of detachment from self-awareness and may reflect defensiveness instead of the distorted self-image characteristic of anorexia nervosa.
C: I am grossly underweight, but that's what I want. Acceptance of being underweight contradicts the typical body image distortion seen in anorexia, where individuals usually deny their actual weight status and desire to lose more weight.
D: I am a few pounds overweight, but I can live with it. This statement reflects a misperception of body weight and suggests a lack of concern about their condition, which does not align with the intense body dissatisfaction found in anorexia nervosa.
Question 5
Regular
A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient's current serum potassium is 2.7 mg/dL. Which nursing diagnosis is most applicable?
Correct!
Incorrect
The correct answer is: D
Rationale
Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia. This diagnosis accurately reflects the severe weight loss and critically low potassium levels due to insufficient nutritional intake over the past five months.
A: Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss. This diagnosis inaccurately attributes the patient's condition to laxative use, which is not mentioned in the history.
B: Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia. Hyperkalemia is not present; instead, hypokalemia is noted, making this diagnosis unsuitable.
C: Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia. There’s no indication of vomiting or swollen glands, thus making this diagnosis irrelevant to the patient's current state.
Correct Answer: D
Rationale: Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia. This diagnosis accurately reflects the severe weight loss and critically low potassium levels due to insufficient nutritional intake over the past five months.
A: Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss. This diagnosis inaccurately attributes the patient's condition to laxative use, which is not mentioned in the history.
B: Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia. Hyperkalemia is not present; instead, hypokalemia is noted, making this diagnosis unsuitable.
C: Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia. There’s no indication of vomiting or swollen glands, thus making this diagnosis irrelevant to the patient's current state.
Question 6
Regular
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: imbalanced nutrition: less than body requirements. Within 1 week, the expectation is that the patient will demonstrate what?
Correct!
Incorrect
The correct answer is: D
Rationale
Demonstrate a gain of 1/2 to 3/4 pound. This outcome directly reflects an improvement in nutritional status and signifies progress towards achieving a balanced diet, essential for recovery from anorexia nervosa.
A: Weigh self accurately using balanced scales. Accurate self-weighing does not ensure nutritional improvement and may reinforce unhealthy behaviors, making it less relevant to the primary nursing diagnosis.
B: Limit exercise to less than 2 hours daily. While managing exercise is important, limiting it alone does not directly address the fundamental issue of nutritional intake and weight gain.
C: Select clothing that fits properly. Choosing appropriate clothing may enhance self-esteem but does not directly correlate with nutritional improvement or address the critical concern of weight gain.
Correct Answer: D
Rationale: Demonstrate a gain of 1/2 to 3/4 pound. This outcome directly reflects an improvement in nutritional status and signifies progress towards achieving a balanced diet, essential for recovery from anorexia nervosa.
A: Weigh self accurately using balanced scales. Accurate self-weighing does not ensure nutritional improvement and may reinforce unhealthy behaviors, making it less relevant to the primary nursing diagnosis.
B: Limit exercise to less than 2 hours daily. While managing exercise is important, limiting it alone does not directly address the fundamental issue of nutritional intake and weight gain.
C: Select clothing that fits properly. Choosing appropriate clothing may enhance self-esteem but does not directly correlate with nutritional improvement or address the critical concern of weight gain.
Question 7
Regular
Which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Observe for adverse effects of refeeding. Monitoring for refeeding syndrome is crucial as patients with anorexia nervosa are at significant risk of complications when they start to gain weight, necessitating careful observation.
A: Assess for depression and anxiety. While mental health is vital, the immediate concern during weight gain is the physiological risks associated with refeeding, not solely the psychological aspects.
C: Communicate empathy for the patient's feelings. Though expressing empathy is important for building rapport, it does not address the urgent health risks that arise during the refeeding process.
D: Help the patient balance energy expenditure and caloric intake. Focusing on balancing energy needs is essential but secondary to ensuring the patient does not experience severe complications from refeeding during this vulnerable time.
Correct Answer: B
Rationale: B: Observe for adverse effects of refeeding. Monitoring for refeeding syndrome is crucial as patients with anorexia nervosa are at significant risk of complications when they start to gain weight, necessitating careful observation.
A: Assess for depression and anxiety. While mental health is vital, the immediate concern during weight gain is the physiological risks associated with refeeding, not solely the psychological aspects.
C: Communicate empathy for the patient's feelings. Though expressing empathy is important for building rapport, it does not address the urgent health risks that arise during the refeeding process.
D: Help the patient balance energy expenditure and caloric intake. Focusing on balancing energy needs is essential but secondary to ensuring the patient does not experience severe complications from refeeding during this vulnerable time.
Question 8
Regular
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?
Correct!
Incorrect
The correct answer is: B
Rationale
Patient involvement in decision making increases a sense of control and promotes compliance with the treatment. Establishing a contract empowers the patient, fostering responsibility and motivation to achieve the specified weekly weight gain in a collaborative manner.
A: Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. While data collection is essential, it does not directly address patient engagement or autonomy in treatment.
C: A team approach to planning the diet ensures that physical and emotional needs of the patient are met. This option emphasizes team collaboration but overlooks the importance of patient empowerment in the decision-making process.
D: Because of increased risk for physical problems with refeeding, obtaining patient permission is required. Although consent is crucial, this choice fails to highlight the significance of the patient's active role in their treatment plan.
Correct Answer: B
Rationale: Patient involvement in decision making increases a sense of control and promotes compliance with the treatment. Establishing a contract empowers the patient, fostering responsibility and motivation to achieve the specified weekly weight gain in a collaborative manner.
A: Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. While data collection is essential, it does not directly address patient engagement or autonomy in treatment.
C: A team approach to planning the diet ensures that physical and emotional needs of the patient are met. This option emphasizes team collaboration but overlooks the importance of patient empowerment in the decision-making process.
D: Because of increased risk for physical problems with refeeding, obtaining patient permission is required. Although consent is crucial, this choice fails to highlight the significance of the patient's active role in their treatment plan.
Question 9
Regular
The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention 'Monitor for complications of refeeding.' Which body system should a nurse closely monitor for dysfunction?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Cardiovascular. Monitoring for complications of refeeding in anorexia nervosa is critical as the cardiovascular system is particularly vulnerable to electrolyte imbalances, which can lead to serious conditions such as arrhythmias and heart failure.
A: Renal. While renal function can be affected during refeeding, the primary concerns revolve around electrolyte shifts impacting the cardiovascular system more significantly.
B: Endocrine. The endocrine system may experience changes during refeeding, yet the most immediate risks involve cardiovascular dysregulation, making it less critical for monitoring in this context.
C: Central nervous. Although central nervous system complications can arise, the acute dangers associated with refeeding primarily affect the cardiovascular system, necessitating closer observation of that area.
Correct Answer: D
Rationale: D: Cardiovascular. Monitoring for complications of refeeding in anorexia nervosa is critical as the cardiovascular system is particularly vulnerable to electrolyte imbalances, which can lead to serious conditions such as arrhythmias and heart failure.
A: Renal. While renal function can be affected during refeeding, the primary concerns revolve around electrolyte shifts impacting the cardiovascular system more significantly.
B: Endocrine. The endocrine system may experience changes during refeeding, yet the most immediate risks involve cardiovascular dysregulation, making it less critical for monitoring in this context.
C: Central nervous. Although central nervous system complications can arise, the acute dangers associated with refeeding primarily affect the cardiovascular system, necessitating closer observation of that area.
Question 10
Regular
A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy?
Correct!
Incorrect
The correct answer is: D
Rationale
Being thin does not seem to solve your problems. You are thin now but still unhappy.
This statement effectively highlights the cognitive therapy approach by challenging the patient's beliefs about thinness equating to happiness, thereby encouraging deeper reflection on the relationship between their body image and emotional well-being.
A: What are your feelings about not eating the food that you prepare? This question invites emotional exploration but does not directly address the underlying cognitive distortions related to anorexia nervosa.
B: You seem to feel much better about yourself when you eat something. This statement assumes the patient experiences positive feelings from eating without directly challenging the core beliefs influencing their eating disorder.
C: It must be difficult to talk about private matters to someone you just met. This comment acknowledges the patient's discomfort but lacks the cognitive restructuring necessary for effective therapy in addressing anorexia nervosa.
Correct Answer: D
Rationale: Being thin does not seem to solve your problems. You are thin now but still unhappy.
This statement effectively highlights the cognitive therapy approach by challenging the patient's beliefs about thinness equating to happiness, thereby encouraging deeper reflection on the relationship between their body image and emotional well-being.
A: What are your feelings about not eating the food that you prepare? This question invites emotional exploration but does not directly address the underlying cognitive distortions related to anorexia nervosa.
B: You seem to feel much better about yourself when you eat something. This statement assumes the patient experiences positive feelings from eating without directly challenging the core beliefs influencing their eating disorder.
C: It must be difficult to talk about private matters to someone you just met. This comment acknowledges the patient's discomfort but lacks the cognitive restructuring necessary for effective therapy in addressing anorexia nervosa.
Question 11
Regular
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges, and purges is to teach the patient what intervention?
Correct!
Incorrect
The correct answer is: B
Rationale
Avoiding skipping meals or restricting food is crucial for a patient with bulimia nervosa, as regular intake helps stabilize eating patterns, reduces binge urges, and promotes healthier relationships with food.
A: Eat a small meal after purging. Consuming food post-purge can reinforce the cycle of bingeing and purging, failing to address the underlying issues of the eating disorder.
C: Concentrate oral intake after 4 pm daily. Limiting intake to a specific time can lead to increased hunger and potential binge episodes, undermining the goal of regular, balanced meals.
D: Understand the value of reading journal entries aloud to others. While sharing experiences can be therapeutic, it does not directly address the critical need for consistent meal patterns in bulimia treatment.
Correct Answer: B
Rationale: Avoiding skipping meals or restricting food is crucial for a patient with bulimia nervosa, as regular intake helps stabilize eating patterns, reduces binge urges, and promotes healthier relationships with food.
A: Eat a small meal after purging. Consuming food post-purge can reinforce the cycle of bingeing and purging, failing to address the underlying issues of the eating disorder.
C: Concentrate oral intake after 4 pm daily. Limiting intake to a specific time can lead to increased hunger and potential binge episodes, undermining the goal of regular, balanced meals.
D: Understand the value of reading journal entries aloud to others. While sharing experiences can be therapeutic, it does not directly address the critical need for consistent meal patterns in bulimia treatment.
Question 12
Regular
What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision?
Correct!
Incorrect
The correct answer is: B
Rationale
The nurse uses an authoritarian manner when interacting with the patient. Such behavior undermines the therapeutic relationship essential for patients with eating disorders, who require empathy and support to foster recovery.
A: The nurse's comments are compassionate and nonjudgmental. This approach is essential in building trust and rapport with patients, promoting a safe environment conducive to healing and open communication.
C: The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. This educational strategy empowers the patient, equipping them with tools to manage their condition effectively and independently.
D: The nurse refers the patient to a self-help group for individuals with eating disorders. This referral demonstrates a commitment to patient-centered care and community support, fostering connections that can enhance recovery.
Correct Answer: B
Rationale: The nurse uses an authoritarian manner when interacting with the patient. Such behavior undermines the therapeutic relationship essential for patients with eating disorders, who require empathy and support to foster recovery.
A: The nurse's comments are compassionate and nonjudgmental. This approach is essential in building trust and rapport with patients, promoting a safe environment conducive to healing and open communication.
C: The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. This educational strategy empowers the patient, equipping them with tools to manage their condition effectively and independently.
D: The nurse refers the patient to a self-help group for individuals with eating disorders. This referral demonstrates a commitment to patient-centered care and community support, fostering connections that can enhance recovery.
Question 13
Regular
A nursing diagnosis for a patient diagnosed with bulimia nervosa is: ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will demonstrate what?
Correct!
Incorrect
The correct answer is: D
Rationale
Demonstration of identification of two alternative methods of coping with loneliness is the best outcome related to this diagnosis. This outcome addresses the patient's ineffective coping mechanisms by promoting healthier strategies to manage feelings of loneliness, which are central to their bulimia nervosa behavior.
A: Appropriate expression of angry feelings focuses on anger management rather than addressing loneliness, which is crucial for the patient’s specific coping struggles related to bulimia nervosa.
B: Verbalization of two positive things about self does not directly tackle the underlying issue of loneliness that prompts overeating and self-induced vomiting, making it less relevant to the diagnosis.
C: Verbalization the importance of eating a balanced diet emphasizes nutritional knowledge rather than coping strategies, which is not the primary concern linked to the patient’s emotional struggles.
Correct Answer: D
Rationale: Demonstration of identification of two alternative methods of coping with loneliness is the best outcome related to this diagnosis. This outcome addresses the patient's ineffective coping mechanisms by promoting healthier strategies to manage feelings of loneliness, which are central to their bulimia nervosa behavior.
A: Appropriate expression of angry feelings focuses on anger management rather than addressing loneliness, which is crucial for the patient’s specific coping struggles related to bulimia nervosa.
B: Verbalization of two positive things about self does not directly tackle the underlying issue of loneliness that prompts overeating and self-induced vomiting, making it less relevant to the diagnosis.
C: Verbalization the importance of eating a balanced diet emphasizes nutritional knowledge rather than coping strategies, which is not the primary concern linked to the patient’s emotional struggles.
Question 14
Regular
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa?
Correct!
Incorrect
The correct answer is: A
Rationale
Assist the patient to identify triggers to binge eating. This intervention is paramount as recognizing triggers allows the patient to understand and manage their behaviors, which is crucial in addressing the underlying psychological factors of bulimia nervosa.
B: Provide corrective consequences for weight loss. Implementing punitive measures can exacerbate feelings of shame and guilt, potentially leading to further disordered eating behaviors rather than promoting healthy change.
C: Explore patient needs for health teaching. While health education is important, it does not address the immediate psychological triggers of binge eating, which must be prioritized for effective intervention.
D: Assess for signs of impulsive eating. Although assessing impulsive eating is beneficial, it focuses on behavior rather than the root causes, which are essential to address for recovery from bulimia nervosa.
Correct Answer: A
Rationale: Assist the patient to identify triggers to binge eating. This intervention is paramount as recognizing triggers allows the patient to understand and manage their behaviors, which is crucial in addressing the underlying psychological factors of bulimia nervosa.
B: Provide corrective consequences for weight loss. Implementing punitive measures can exacerbate feelings of shame and guilt, potentially leading to further disordered eating behaviors rather than promoting healthy change.
C: Explore patient needs for health teaching. While health education is important, it does not address the immediate psychological triggers of binge eating, which must be prioritized for effective intervention.
D: Assess for signs of impulsive eating. Although assessing impulsive eating is beneficial, it focuses on behavior rather than the root causes, which are essential to address for recovery from bulimia nervosa.
Question 15
Regular
One bed is available on the inpatient eating disorders unit. Which patient experiencing a weight should be admitted?
Correct!
Incorrect
The correct answer is: A
Rationale
A: The patient with a weight loss of 150 to 100 pounds over four months should be admitted. This significant weight loss, along with critical vital signs, indicates a severe medical risk requiring immediate intervention.
B: The patient with a weight loss of 120 to 90 pounds over three months shows concerning vital signs but does not present the same level of critical health risk as option A.
C: The patient with a weight loss of 110 to 70 pounds over four months has stable vital signs and does not demonstrate the acute medical instability seen in option A, making them less urgent for admission.
D: The patient with a weight loss of 90 to 78 pounds over five months shows the least significant weight loss and stable vital signs, indicating a lower priority for immediate inpatient care compared to option A.
Correct Answer: A
Rationale: A: The patient with a weight loss of 150 to 100 pounds over four months should be admitted. This significant weight loss, along with critical vital signs, indicates a severe medical risk requiring immediate intervention.
B: The patient with a weight loss of 120 to 90 pounds over three months shows concerning vital signs but does not present the same level of critical health risk as option A.
C: The patient with a weight loss of 110 to 70 pounds over four months has stable vital signs and does not demonstrate the acute medical instability seen in option A, making them less urgent for admission.
D: The patient with a weight loss of 90 to 78 pounds over five months shows the least significant weight loss and stable vital signs, indicating a lower priority for immediate inpatient care compared to option A.
Question 16
Regular
While providing health teaching for a patient diagnosed with bulimia nervosa, what information should a nurse emphasize?
Correct!
Incorrect
The correct answer is: C
Rationale
Recognizing symptoms of hypokalemia. Emphasizing this information is crucial since individuals with bulimia nervosa often engage in purging behaviors that can lead to dangerous potassium depletion, resulting in severe health complications.
A: Self-monitoring of daily food and fluid intake. While important, this focus overlooks the immediate health risks associated with electrolyte imbalances, which are critical for patients experiencing bulimia nervosa.
B: Establishing the desired daily weight gain. Weight gain is a longer-term goal; prioritizing immediate health concerns like potassium levels is essential for safeguarding the patient's well-being.
D: Self-esteem maintenance. Although relevant to recovery, addressing hypokalemia symptoms takes precedence to ensure the patient’s physical health is stabilized before tackling psychological aspects.
Correct Answer: C
Rationale: Recognizing symptoms of hypokalemia. Emphasizing this information is crucial since individuals with bulimia nervosa often engage in purging behaviors that can lead to dangerous potassium depletion, resulting in severe health complications.
A: Self-monitoring of daily food and fluid intake. While important, this focus overlooks the immediate health risks associated with electrolyte imbalances, which are critical for patients experiencing bulimia nervosa.
B: Establishing the desired daily weight gain. Weight gain is a longer-term goal; prioritizing immediate health concerns like potassium levels is essential for safeguarding the patient's well-being.
D: Self-esteem maintenance. Although relevant to recovery, addressing hypokalemia symptoms takes precedence to ensure the patient’s physical health is stabilized before tackling psychological aspects.
Question 17
Regular
As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which condition should be documented?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Lanugo. The presence of fine, downy hair on the patient's body indicates lanugo, a common physiological response in individuals with severe malnutrition or eating disorders, reflecting the body's attempt to maintain warmth.
A: Amenorrhea. While amenorrhea may occur with significant weight loss, it specifically refers to the absence of menstruation and does not relate to the observation of fine hair.
B: Alopecia. Alopecia describes hair loss, typically characterized by bald patches or thinning hair, which does not align with the observation of fine, downy hair on the patient's body.
D: Stupor. Stupor refers to a state of near-unconsciousness or insensibility, which does not correlate with the noted physical sign of lanugo in the patient’s condition.
Correct Answer: C
Rationale: C: Lanugo. The presence of fine, downy hair on the patient's body indicates lanugo, a common physiological response in individuals with severe malnutrition or eating disorders, reflecting the body's attempt to maintain warmth.
A: Amenorrhea. While amenorrhea may occur with significant weight loss, it specifically refers to the absence of menstruation and does not relate to the observation of fine hair.
B: Alopecia. Alopecia describes hair loss, typically characterized by bald patches or thinning hair, which does not align with the observation of fine, downy hair on the patient's body.
D: Stupor. Stupor refers to a state of near-unconsciousness or insensibility, which does not correlate with the noted physical sign of lanugo in the patient’s condition.
Question 18
Regular
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, 'I won't eat until I look thin.' What is the priority initial nursing diagnosis?
Correct!
Incorrect
The correct answer is: D
Rationale
Imbalanced nutrition: less than body requirements, related to self-starvation. This diagnosis is prioritized as the patient exhibits significant weight loss, malnutrition, and an active refusal to eat, indicating severe nutritional deficiency.
A: Anxiety, related to fear of weight gain. While anxiety may be present, the immediate concern is the patient's serious nutritional state rather than anxiety management at this stage.
B: Disturbed body image, related to weight loss. Although body image issues are significant in eating disorders, the urgent need to address life-threatening malnutrition takes precedence over perceptions of body image.
C: Ineffective coping, related to lack of conflict resolution skills. Coping strategies are relevant; however, the critical issue remains the acute nutritional deficiency stemming from self-imposed starvation, necessitating immediate intervention.
Correct Answer: D
Rationale: Imbalanced nutrition: less than body requirements, related to self-starvation. This diagnosis is prioritized as the patient exhibits significant weight loss, malnutrition, and an active refusal to eat, indicating severe nutritional deficiency.
A: Anxiety, related to fear of weight gain. While anxiety may be present, the immediate concern is the patient's serious nutritional state rather than anxiety management at this stage.
B: Disturbed body image, related to weight loss. Although body image issues are significant in eating disorders, the urgent need to address life-threatening malnutrition takes precedence over perceptions of body image.
C: Ineffective coping, related to lack of conflict resolution skills. Coping strategies are relevant; however, the critical issue remains the acute nutritional deficiency stemming from self-imposed starvation, necessitating immediate intervention.
Question 19
Regular
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for what primary purpose?
Correct!
Incorrect
The correct answer is: D
Rationale
Scheduling group therapy sessions immediately after meals serves the primary purpose of processing the heightened anxiety associated with eating. This timing allows patients to address their feelings and thoughts related to food consumption, promoting emotional regulation and coping strategies in a supportive environment.
A: Maintaining patients' concentration and attention. Concentration may not be the focus immediately after meals, as patients often experience a mix of emotions that require processing, not just attention management.
B: Shifting the patients' focus from food to psychotherapy. While therapy may redirect focus, the immediate post-meal period is crucial for addressing anxiety directly linked to recent eating experiences rather than simply shifting attention.
C: Focusing on weight control mechanisms and food preparation. The priority after meals should be emotional processing rather than practical aspects of weight control or preparation, which are not primary concerns in this context.
Correct Answer: D
Rationale: Scheduling group therapy sessions immediately after meals serves the primary purpose of processing the heightened anxiety associated with eating. This timing allows patients to address their feelings and thoughts related to food consumption, promoting emotional regulation and coping strategies in a supportive environment.
A: Maintaining patients' concentration and attention. Concentration may not be the focus immediately after meals, as patients often experience a mix of emotions that require processing, not just attention management.
B: Shifting the patients' focus from food to psychotherapy. While therapy may redirect focus, the immediate post-meal period is crucial for addressing anxiety directly linked to recent eating experiences rather than simply shifting attention.
C: Focusing on weight control mechanisms and food preparation. The priority after meals should be emotional processing rather than practical aspects of weight control or preparation, which are not primary concerns in this context.
Question 20
Regular
Physical assessment of a patient diagnosed with bulimia nervosa often reveals what data?
Correct!
Incorrect
The correct answer is: A
Rationale
Prominent parotid glands are often revealed during the physical assessment of a patient diagnosed with bulimia nervosa. This enlargement occurs due to recurrent vomiting, which stimulates the salivary glands, leading to noticeable swelling.
B: Peripheral edema can occur in various conditions but is not specifically associated with bulimia nervosa. It typically indicates fluid retention rather than the physiological effects of the eating disorder.
C: Thin, brittle hair may be present in individuals with bulimia nervosa, but it is more indicative of malnutrition rather than a primary physical assessment finding. Hair condition varies significantly among patients.
D: Amenorrhea can be a symptom of bulimia nervosa, yet it is not universally present in all cases. Many patients may still have regular menstrual cycles despite the disorder's effects.
Correct Answer: A
Rationale: Prominent parotid glands are often revealed during the physical assessment of a patient diagnosed with bulimia nervosa. This enlargement occurs due to recurrent vomiting, which stimulates the salivary glands, leading to noticeable swelling.
B: Peripheral edema can occur in various conditions but is not specifically associated with bulimia nervosa. It typically indicates fluid retention rather than the physiological effects of the eating disorder.
C: Thin, brittle hair may be present in individuals with bulimia nervosa, but it is more indicative of malnutrition rather than a primary physical assessment finding. Hair condition varies significantly among patients.
D: Amenorrhea can be a symptom of bulimia nervosa, yet it is not universally present in all cases. Many patients may still have regular menstrual cycles despite the disorder's effects.
Question 21
Regular
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa?
Correct!
Incorrect
The correct answer is: B
Rationale
Rigidity, perfectionism. Patients with anorexia nervosa often exhibit a need for control and high standards, leading to inflexible thinking and behaviors. These traits are key indicators that nurses assess when evaluating the psychological aspects of this eating disorder.
A: Carefree flexibility. This trait contradicts the nature of anorexia nervosa, where patients typically display a lack of adaptability and an aversion to spontaneity in their behaviors and choices.
C: Open displays of emotion. Individuals with anorexia nervosa often suppress emotions, leading to a lack of emotional expression, which is contrary to the idea of openly displaying feelings.
D: High spirits and optimism. Anorexia nervosa is frequently associated with low mood and pessimism, making high spirits and optimism unlikely characteristics in patients suffering from this disorder.
Correct Answer: B
Rationale: Rigidity, perfectionism. Patients with anorexia nervosa often exhibit a need for control and high standards, leading to inflexible thinking and behaviors. These traits are key indicators that nurses assess when evaluating the psychological aspects of this eating disorder.
A: Carefree flexibility. This trait contradicts the nature of anorexia nervosa, where patients typically display a lack of adaptability and an aversion to spontaneity in their behaviors and choices.
C: Open displays of emotion. Individuals with anorexia nervosa often suppress emotions, leading to a lack of emotional expression, which is contrary to the idea of openly displaying feelings.
D: High spirits and optimism. Anorexia nervosa is frequently associated with low mood and pessimism, making high spirits and optimism unlikely characteristics in patients suffering from this disorder.
Question 22
Regular
Which assessment finding for a patient diagnosed with an eating disorder meets a criterion for hospitalization?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Systolic blood pressure: 62 mm Hg indicates severe hypotension, which can lead to life-threatening complications. This finding signifies a critical need for hospitalization to ensure the patient's safety and effective monitoring.
A: Urine output: 40 mL/hr does not indicate immediate danger; it falls within a relatively normal range and does not suggest acute renal failure or dehydration requiring hospitalization.
B: Pulse rate: 58 beats/min is considered bradycardia but does not necessarily require hospitalization unless accompanied by other critical symptoms or complications affecting the patient's stability.
C: Serum potassium: 3.4 mEq/L is within a normal range, indicating that there is no immediate risk of hypokalemia-related complications requiring urgent intervention or hospitalization for this patient.
Correct Answer: D
Rationale: D: Systolic blood pressure: 62 mm Hg indicates severe hypotension, which can lead to life-threatening complications. This finding signifies a critical need for hospitalization to ensure the patient's safety and effective monitoring.
A: Urine output: 40 mL/hr does not indicate immediate danger; it falls within a relatively normal range and does not suggest acute renal failure or dehydration requiring hospitalization.
B: Pulse rate: 58 beats/min is considered bradycardia but does not necessarily require hospitalization unless accompanied by other critical symptoms or complications affecting the patient's stability.
C: Serum potassium: 3.4 mEq/L is within a normal range, indicating that there is no immediate risk of hypokalemia-related complications requiring urgent intervention or hospitalization for this patient.
Question 23
Regular
Which statement is a nurse most likely to hear from a patient diagnosed with anorexia nervosa?
Correct!
Incorrect
The correct answer is: A
Rationale
I would be happy if I could lose 20 more pounds. This statement reflects a common thought pattern in anorexia nervosa, where patients often focus on weight loss as a means to achieve happiness and self-worth, demonstrating their distorted body image and unhealthy relationship with food and weight.
B: My parents don't pay much attention to me. While this may reflect a patient's emotional state, it does not directly relate to their perception of body image or weight issues.
C: I'm thin for my height. This statement indicates a potential awareness of body weight but does not capture the desire for further weight loss typical in anorexia nervosa patients.
D: I have nice eyes. This comment highlights a positive self-perception unrelated to body image and weight concerns, which are central to the dialogue of individuals suffering from anorexia nervosa.
Correct Answer: A
Rationale: I would be happy if I could lose 20 more pounds. This statement reflects a common thought pattern in anorexia nervosa, where patients often focus on weight loss as a means to achieve happiness and self-worth, demonstrating their distorted body image and unhealthy relationship with food and weight.
B: My parents don't pay much attention to me. While this may reflect a patient's emotional state, it does not directly relate to their perception of body image or weight issues.
C: I'm thin for my height. This statement indicates a potential awareness of body weight but does not capture the desire for further weight loss typical in anorexia nervosa patients.
D: I have nice eyes. This comment highlights a positive self-perception unrelated to body image and weight concerns, which are central to the dialogue of individuals suffering from anorexia nervosa.
Question 24
Regular
Which nursing diagnosis is more applicable for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Imbalanced nutrition: less than body requirements. This diagnosis applies more to the anorexia nervosa patient, who is significantly underweight and restricting food intake, leading to severe nutritional deficiencies and health risks.
A: Powerlessness. While feelings of powerlessness can be associated with both disorders, they do not primarily define the nutritional aspect critical in the context of anorexia nervosa.
B: Ineffective coping. This diagnosis may apply to both patients; however, it does not specifically address the acute nutritional deficit present in the patient with anorexia nervosa.
C: Disturbed body image. Although body image issues are pertinent to both conditions, this diagnosis does not capture the immediate and severe nutritional concerns faced by the anorexic patient.
Correct Answer: D
Rationale: D: Imbalanced nutrition: less than body requirements. This diagnosis applies more to the anorexia nervosa patient, who is significantly underweight and restricting food intake, leading to severe nutritional deficiencies and health risks.
A: Powerlessness. While feelings of powerlessness can be associated with both disorders, they do not primarily define the nutritional aspect critical in the context of anorexia nervosa.
B: Ineffective coping. This diagnosis may apply to both patients; however, it does not specifically address the acute nutritional deficit present in the patient with anorexia nervosa.
C: Disturbed body image. Although body image issues are pertinent to both conditions, this diagnosis does not capture the immediate and severe nutritional concerns faced by the anorexic patient.
Question 25
Regular
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should implement what intervention to assess patient safety?
Correct!
Incorrect
The correct answer is: A
Rationale
Assess lung sounds and extremities. Monitoring lung sounds is crucial during refeeding due to the risk of fluid overload and potential heart complications. Assessing extremities can help identify any signs of edema or circulatory issues, ensuring the patient's safety during this critical phase of recovery.
B: Suggest the use of an aerobic exercise program. Implementing an exercise program during refeeding may exacerbate the patient's condition and lead to further complications, contradicting the focus on stabilization and health.
C: Positively reinforce the patient for the weight gain. While reinforcement is important, it does not directly address the immediate health risks associated with rapid weight gain, which may compromise patient safety.
D: Establish a higher goal for weight gain the next week. Setting a higher weight gain target could pressure the patient and overlook the need for careful monitoring of their physiological response to refeeding.
Correct Answer: A
Rationale: Assess lung sounds and extremities. Monitoring lung sounds is crucial during refeeding due to the risk of fluid overload and potential heart complications. Assessing extremities can help identify any signs of edema or circulatory issues, ensuring the patient's safety during this critical phase of recovery.
B: Suggest the use of an aerobic exercise program. Implementing an exercise program during refeeding may exacerbate the patient's condition and lead to further complications, contradicting the focus on stabilization and health.
C: Positively reinforce the patient for the weight gain. While reinforcement is important, it does not directly address the immediate health risks associated with rapid weight gain, which may compromise patient safety.
D: Establish a higher goal for weight gain the next week. Setting a higher weight gain target could pressure the patient and overlook the need for careful monitoring of their physiological response to refeeding.
Question 26
Regular
When observing a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, what response should the nurse provide?
Correct!
Incorrect
The correct answer is: D
Rationale
D: According to our agreement, no exercising is permitted until you have gained a specific amount of weight. This response directly reinforces the established guidelines for the patient's recovery process, emphasizing the importance of adhering to the treatment plan.
A: You and I will have to sit down and discuss this problem. This response lacks immediacy and does not address the urgency of the situation regarding the patient’s health.
B: It bothers me to see you exercising. You'll lose more weight. This reaction focuses on the nurse's feelings rather than providing constructive guidance or reinforcing the treatment protocol effectively.
C: Let's discuss the relationship between exercise and weight loss and how that affects your body. While informative, this option does not address the immediate need to uphold the no-exercise agreement crucial for the patient's recovery.
Correct Answer: D
Rationale: D: According to our agreement, no exercising is permitted until you have gained a specific amount of weight. This response directly reinforces the established guidelines for the patient's recovery process, emphasizing the importance of adhering to the treatment plan.
A: You and I will have to sit down and discuss this problem. This response lacks immediacy and does not address the urgency of the situation regarding the patient’s health.
B: It bothers me to see you exercising. You'll lose more weight. This reaction focuses on the nurse's feelings rather than providing constructive guidance or reinforcing the treatment protocol effectively.
C: Let's discuss the relationship between exercise and weight loss and how that affects your body. While informative, this option does not address the immediate need to uphold the no-exercise agreement crucial for the patient's recovery.
Question 27
Regular
A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m┬▓. Which assessment finding is most likely to accompany this value?
Correct!
Incorrect
The correct answer is: A
Rationale
Cachexia. A BMI of 14.8 kg/m² indicates severe malnutrition, commonly associated with anorexia nervosa, leading to significant muscle wasting and weight loss, which are hallmark features of cachexia in such patients.
B: Leukocytosis. This condition typically signifies an infection or inflammation rather than malnutrition, and patients with anorexia nervosa often exhibit low white blood cell counts due to nutritional deficiencies.
C: Hyperthermia. Elevated body temperature generally results from infections or heat-related illnesses, not from low body weight or anorexia, where patients often experience lower-than-normal body temperatures instead.
D: Hypertension. High blood pressure is not a common finding in individuals with anorexia nervosa, as they typically present with hypotension due to volume depletion and nutritional deficiencies.
Correct Answer: A
Rationale: Cachexia. A BMI of 14.8 kg/m² indicates severe malnutrition, commonly associated with anorexia nervosa, leading to significant muscle wasting and weight loss, which are hallmark features of cachexia in such patients.
B: Leukocytosis. This condition typically signifies an infection or inflammation rather than malnutrition, and patients with anorexia nervosa often exhibit low white blood cell counts due to nutritional deficiencies.
C: Hyperthermia. Elevated body temperature generally results from infections or heat-related illnesses, not from low body weight or anorexia, where patients often experience lower-than-normal body temperatures instead.
D: Hypertension. High blood pressure is not a common finding in individuals with anorexia nervosa, as they typically present with hypotension due to volume depletion and nutritional deficiencies.
Question 28
Multiple Choice
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess?
Correct!
Incorrect
The correct answer is: A,C,D,F
Rationale
A: Hypothermia, Constipation, Hypotension, Lanugo.
The context describes a significant weight loss and amenorrhea, which are indicative of anorexia nervosa. Physical manifestations such as hypothermia, constipation, hypotension, and lanugo are commonly observed in patients suffering from this disorder, as their bodies struggle to maintain homeostasis and adequate nutrition.
B: Parotid swelling. This symptom is more commonly associated with bulimia nervosa due to repeated vomiting rather than anorexia nervosa, where weight loss predominates without such behaviors.
E: Dental caries. Dental issues arise primarily from frequent vomiting in bulimia nervosa, not from the restrictive eating patterns observed in anorexia nervosa, leading to different oral health concerns.
Correct Answer: A,C,D,F
Rationale: A: Hypothermia, Constipation, Hypotension, Lanugo.
The context describes a significant weight loss and amenorrhea, which are indicative of anorexia nervosa. Physical manifestations such as hypothermia, constipation, hypotension, and lanugo are commonly observed in patients suffering from this disorder, as their bodies struggle to maintain homeostasis and adequate nutrition.
B: Parotid swelling. This symptom is more commonly associated with bulimia nervosa due to repeated vomiting rather than anorexia nervosa, where weight loss predominates without such behaviors.
E: Dental caries. Dental issues arise primarily from frequent vomiting in bulimia nervosa, not from the restrictive eating patterns observed in anorexia nervosa, leading to different oral health concerns.
Question 29
Multiple Choice
A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide?
Correct!
Incorrect
The correct answer is: C,D,E
Rationale
A: Adherence to a selected menu. This option promotes structure and accountability in the treatment of anorexia nervosa, ensuring patients receive balanced nutrition while adhering to a carefully planned dietary regimen.
D: Observation during and after meals. This ensures that patients are monitored for any potential harmful behaviors related to eating, which is crucial for their safety and recovery.
E: Monitoring during bathroom trips. This measure helps prevent engaging in purging behaviors, a common issue in anorexia nervosa, thus safeguarding the patient's health during treatment.
B: Unscheduled weight checks. This approach could induce anxiety and stress, undermining the therapeutic environment crucial for recovery. Predictability and routine are far more beneficial for patients.
F: Privileges correlated with emotional expression. While emotional expression is important, linking privileges to this may not directly aid in the structured treatment framework necessary for managing anorexia nervosa effectively.
Correct Answer: C,D,E
Rationale: A: Adherence to a selected menu. This option promotes structure and accountability in the treatment of anorexia nervosa, ensuring patients receive balanced nutrition while adhering to a carefully planned dietary regimen.
D: Observation during and after meals. This ensures that patients are monitored for any potential harmful behaviors related to eating, which is crucial for their safety and recovery.
E: Monitoring during bathroom trips. This measure helps prevent engaging in purging behaviors, a common issue in anorexia nervosa, thus safeguarding the patient's health during treatment.
B: Unscheduled weight checks. This approach could induce anxiety and stress, undermining the therapeutic environment crucial for recovery. Predictability and routine are far more beneficial for patients.
F: Privileges correlated with emotional expression. While emotional expression is important, linking privileges to this may not directly aid in the structured treatment framework necessary for managing anorexia nervosa effectively.