A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Encourage the client to look at the balance beam

Have the client wear the same clothing every day.

Weigh the client at the same time in the morning

Use the same scale to weigh the client.

Discuss the client's weight with her after each measurement.

Answer and Explanation

Correct Answer : B,C,D

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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Correct Answer is D

Explanation

A) Size:

When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.

B) Consistency:

The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.

C) Shape:

Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.

D) Color:

Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.

A. diarrhea B. diaphoresis C. fainting D. vomiting

Correct Answer is C

Explanation

(a) Diarrhea: Diarrhea is an abnormal gastrointestinal response characterized by frequent, loose, or watery stools. It can be caused by infections, medications, or underlying gastrointestinal disorders. Pallor, or paleness of the skin, typically does not directly lead to diarrhea unless there are specific underlying conditions affecting both circulation and gastrointestinal function.

(b) Diaphoresis: Diaphoresis refers to excessive sweating, which can occur due to sympathetic nervous system activation, fever, or anxiety. While diaphoresis may be associated with conditions causing increased sympathetic activity, it is not directly related to pallor, which indicates reduced blood flow to the skin.

(c) Fainting: Pallor is often a sign of decreased blood flow to the skin, indicating potential hypoperfusion. If severe, this reduced circulation can lead to fainting (syncope) due to inadequate blood supply to the brain. Therefore, after noting pallor, the nurse should be prepared to manage the client for potential fainting episodes by ensuring safety and providing appropriate interventions.

(d) Vomiting: Vomiting is the forceful expulsion of stomach contents through the mouth and can be caused by various factors such as gastrointestinal irritation, infection, or systemic illnesses. Pallor does not directly cause vomiting, although severe systemic conditions affecting circulation could potentially lead to nausea and vomiting as part of a broader clinical picture.

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A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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