A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?
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Solution
Initiating caloric and nutritional therapy as ordered
Option A: The client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes the highest priority.
Options B and C: Behavioral modification (in which client privileges depend on weight gain) and psychoanalysis (which addresses the client’s low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client’s physical condition.
Option D: Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn’t take precedence over providing adequate caloric intake to ensure survival
A client who’s actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP?
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Solution
Nystagmus
Option B: Phencyclidine is an anesthetic with severe psychological effects. It blocks the reuptake of dopamine and directly affects the midbrain and thalamus. Nystagmus and ataxia are common physical findings of PCP use.
Option A: Dilated pupils are evidence of LSD ingestion.
Options C and D: Paranoia and altered mood occur with both PCP and LSD ingestion.
Which of the following is important when restraining a violent client?
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Solution
Have an organized, efficient team approach after the decision is made to restrain the client.
Option C: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process.
Option A: The leader, located at the client’s head, should take charge; four staff members are required to hold and restrain the limbs.
Option B: For safety reasons, restraints should be fastened to the bed frame instead of the side rails.
Option D: For quick release, loops should be used instead of knots
During which phase of alcoholism is loss of control and physiologic dependence evident?
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Solution
Crucial phase
Option C: The crucial phase is marked by physical dependence.
Option A: The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stress.
Option B: The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol.
Option D: The chronic phase is characterized by emotional and physical deterioration.
A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written:
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Solution
jointly by the client and nurse.
Option C: A contract written jointly by the client and nurse most successfully promotes cooperation and consistent behavior.
Option A: The most effective contract — and the type least likely to allow for manipulation and misinterpretation — states the behavioral terms as concretely as possible.
Options B and D: A contract written solely by the client may not be agreeable to staff members; one written by the physician and nurse may not be agreeable to the client.
A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, “I’m not going to those meetings anymore. I’m not like the rest of those people. I’m not a drunk. “What is the most appropriate response?
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Solution
“You seem upset about the meetings.”
Option C: The substance abuser uses the substance to cope with feelings and may deny the abuse. Asking if the client is upset about the meetings encourages the client to identify and deal with feelings instead of covering them up.
Options A and D: Arguing with the client about the substance abuse or insisting that the client attend the meetings wouldn’t help the client identify resistance to treatment.
Option B: This isn’t therapeutic behavior because it plays down the importance of attending meetings.
A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse?
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Solution
“I hope you’ll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable.”
Option B: Clients with anorexia can refuse food to the point of cardiac damage. Tube feedings and I.V. infusions are ordered to prevent such damage. The nurse is informing her of her treatment options.
Option A: This doesn’t tell the client about the consequences of choosing not to eat.
Options C and D: Telling clients that they are too thin won’t change their self-image.
A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4″ (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can’t remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has:
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Solution
anorexia nervosa.
Option B: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. Typically, the client
is hypotensive and dehydrated. Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death.Option A: Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting.
Option C: Although depression may be accompanied by weight loss, it isn’t characterized by a body image disturbance or the intense fear of obesity seen in anorexia nervosa.
Option D: Schizophrenia may cause bizarre eating patterns, but it rarely causes the full syndrome of anorexia nervosa.
In a toddler, which of the following injuries is most likely the result of child abuse?
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Solution
Several small, dime-sized circular burns on the child’s back
Option C: Small circular burns on a child’s back are no accident and may be from cigarettes.
Options A and B: Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren’t uncommon.
Option D: A small area of ecchymosis isn’t suspicious in this age-group.
An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn’t know what to do with her life. She says she has quit her last five jobs because her coworkers didn’t like her and didn’t train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client’s initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis?
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Solution
Lack of self-esteem, strong dependency needs, and impulsive behavior
Option C: Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships, mood, and poor self-image also is common. Typically, the client can’t tolerate being alone and expresses feelings of emptiness or boredom.
Option A: Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder.
Option B: Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders.
Option D: In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent