A nurse is collecting data from a client who has bulimia nervosa.
Which of the following findings should the nurse expect?

Lanugo.

Muscle wasting.

Hypokalemia.

Hypomagnesemia.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Lanugo, fine hair growth on the skin, is more commonly associated with anorexia nervosa rather than bulimia nervosa. It develops as the body's response to severe weight loss and malnutrition in anorexia, and is not a typical finding in bulimia nervosa, which involves binge eating and purging behaviors.

Choice B rationale

Muscle wasting is more characteristic of anorexia nervosa due to prolonged starvation and insufficient protein intake. While bulimia nervosa can lead to nutritional deficiencies, muscle wasting is less common compared to the profound weight loss seen in anorexia nervosa.

Choice C rationale

Hypokalemia, low potassium levels, is a common finding in bulimia nervosa due to repeated episodes of vomiting and use of laxatives or diuretics. These behaviors lead to significant electrolyte imbalances, including potassium loss, which can cause serious cardiac and muscular complications.

Choice D rationale

Hypomagnesemia, low magnesium levels, can occur in individuals with bulimia nervosa due to poor dietary intake and frequent purging. However, it is less commonly recognized as a primary finding compared to hypokalemia. Monitoring and correcting electrolyte imbalances are essential in the management of bulimia nervosa.

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Correct Answer is []

Explanation

Condition: Delirium.

2 actions:

Encourage family members to stay with the client,

Monitor the client's fluid intake and output.

2 parameters:

Fall risk,

Sleep-wake cycle.

Rationale for correct condition: Delirium is indicated by the sudden onset of disorientation, confusion, and changes in mental status. Postoperative status, dehydration, and infection contribute to delirium. The client's symptoms began recently and are acute. Delirium often presents with restlessness and disturbed sleep. Immediate intervention is crucial to prevent further deterioration.

Rationale for actions: Family presence provides reassurance and helps reorient the client. Familiar faces can reduce anxiety and confusion. Monitoring fluid intake and output addresses dehydration, a common delirium trigger. Ensuring proper hydration can improve mental status. Identifying coping skills is less urgent in acute delirium. Encouraging exercise is inappropriate until the client stabilizes.

Rationale for parameters: Monitoring fall risk is crucial due to the client's confusion and agitation. Preventing falls ensures safety. Tracking the sleep-wake cycle helps assess delirium severity and improvement. Delirium often disrupts sleep patterns. Suicidal ideation is less likely related to delirium. Weight loss is not an immediate concern. Oxygen saturation is stable, irrelevant for delirium.

Rationale for incorrect conditions: Depression presents with prolonged low mood, not sudden confusion. Alzheimer's disease involves gradual cognitive decline, unlike acute delirium. Generalized anxiety disorder does not explain acute disorientation and restlessness.

A. A client who is repeatedly approaching the nurses' station to request medication for his anxiety. B. A client who is standing in her room, yelling obscenities, and throwing her clothes. C. A client who has bipolar disorder and is continuously pacing at the end of the hall. D. A client in the dayroom who is screaming at other clients about what is on the television.

Correct Answer is B

Explanation

Choice A rationale

While this client may need attention, the behavior is not immediately dangerous.

Choice B rationale

This client requires immediate attention due to the risk of harm to herself and others through throwing objects and yelling, which indicates potential for escalation.

Choice C rationale

Pacing, although concerning, does not pose an immediate risk of physical harm compared to Choice B.

Choice D rationale

The client is disruptive but not immediately dangerous compared to the client in Choice B who poses a more direct risk.

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A nurse is collecting data from a client who has bulimia nervosa.Which of the following findings should the nurse expect?

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Correct Answer is []

Explanation

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A nurse is collecting data from a client who has bulimia nervosa.
Which of the following findings should the nurse expect?