A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
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Solution
Patient will learn problem-solving skills
If the client learns problem-solving skills she will gain a sense of control over her life.
Option B: Anxiety is caused by powerlessness.
Option C: Performing self-care activities will not decrease one’s powerlessness.
Option D: Setting limits to control imposed by others is a necessary skill but problem-solving skill is the priority.
The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individual
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Solution
Have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time.
Options B and C are characteristics of a client with anorexia nervosa.
Option D: Low esteem is noted in both eating disorders
The client with anorexia nervosa is improving if:
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Solution
Weight gain
Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week.
Option A: The client may purge after eating.
Option C: Attending an activity does not indicate improvement in the nutritional state.
Option D: Body image is a factor in anorexia nervosa, but it is not an indicator of improvement.
What is the best intervention to teach the client when she feels the need to starve?
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Solution
Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping.
Option A: Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists.
Option B: The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight.
Option D: The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.
Situation: A 17-year-old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client?
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Solution
Fluid volume deficit
Fluid volume deficit is the priority over altered nutrition since the situation indicates that the client is dehydrated.
Options A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.
Dementia, unlike delirium, is characterized by:
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Solution
Insidious onset
Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances.
Options A, C, and D are all characteristics of delirium.
She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is:
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Solution
“Your husband is dead. Let me serve you your breakfast.”
The client should be reoriented to reality and be focused on the here and now.
Option B: This is not a helpful approach because of the short term memory of the client.
Option C: This indicates a pompous response.
Option D: The cognitive limitation of the client makes the client incapable of giving an explanation.
The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
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Solution
Remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability deteriorates.
Option A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority
Option B: Patient is allowed to reminisce but it is not the priority.
Option D: The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently
She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic?
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Solution
“This must be difficult for you and your mother.”
This reflecting the feeling of the daughter that shows empathy.
Options A and D. Giving advice does not encourage verbalization.
Option B: This response does not encourage verbalization of feelings.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
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Solution
Agnosia
This is the inability to recognize objects.
Option A: Apraxia is the inability to execute motor activities despite intact comprehension.
Option B: Aphasia is the loss of ability to use or understand words.
Option D: Amnesia is loss of memory.