During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2.

Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Measure the client's blood pressure in both arms.

Screen for a family history of diabetes mellitus.

Arrange for immediate transport to a medical facility.

Advise the client to restrict fluids and keep feet elevated.

Discuss the importance of a regular exercise program.

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:
Measuring blood pressure in both arms can help assess for potential hypertension, which is a common concern in individuals with abdominal obesity and a high waist-hip ratio.

Choice B rationale:
Screening for a family history of diabetes mellitus is important because individuals with abdominal obesity are at increased risk for type 2 diabetes.

Choice C rationale:
Immediate transport to a medical facility is not indicated based solely on the findings of abdominal obesity, high waist-hip ratio, and elevated BMI. These findings may indicate an increased risk for certain health conditions, but they do not necessitate emergency transport.

Choice D rationale:
Restricting fluids and elevating feet is not a standard intervention based solely on the findings described. This action would be more relevant in specific medical situations, such as managing edema.

Choice E rationale:
Discussing the importance of a regular exercise program is appropriate because it can help address obesity and its associated health risks, including diabetes and hypertension.

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Correct Answer is A

Explanation

Choice A rationale:
Spending time sitting in silence with the client can be a therapeutic intervention for someone who is depressed and experiencing delayed responses. It allows the client to feel a sense of presence and support without the pressure to speak or respond immediately.
This approach can help create a safe and non-judgmental environment for the client to express themselves when they are ready.

Choice B rationale:
Involving the client in a daily exercise program may be a beneficial part of the overall care plan for managing depression, but it does not directly address the client's delayed responses during interactions.

Choice C rationale:
Asking the client to describe her depression may be a useful therapeutic intervention to explore the client's feelings and experiences, but it should be done in a way that respects the client's pace and readiness to discuss her emotions.

Choice D rationale:
Observing for signs of possible psychosis is important for assessing the client's mental health, but delayed responses alone may not necessarily indicate psychosis. It's essential to consider the broader clinical picture and conduct a comprehensive assessment.

A. Provide a supportive, structured environment for meals. B. Assess weight, vital signs, potassium, and other electrolytes. C. Discuss alternative strategies for binging and purging. D. Monitor the client after meals for possible vomiting.

Correct Answer is B

Explanation

Choice A rationale:
Providing a supportive, structured environment for meals is an important aspect of the overall care plan for individuals with bulimia. However, it should not be the first intervention when a client is admitted with potential physical complications. Addressing the client's physical condition and safety is the initial priority.

Choice B rationale:
This is the correct initial intervention. Bulimia can lead to severe medical complications, including electrolyte imbalances, which can be life-threatening. Assessing the client's weight, vital signs, and electrolyte levels is crucial to determine the severity of physical issues and guide appropriate medical interventions.

Choice C rationale:
Discussing alternative strategies for binging and purging is an important aspect of treatment for bulimia, but it should follow the initial assessment of the client's physical condition. Addressing the client's medical needs takes precedence over discussing alternatives.

Choice D rationale:
While monitoring the client for possible vomiting is important in the care of individuals with bulimia, it should not be the first intervention when the client is admitted. Assessing the client's physical status and addressing potential medical complications should come before monitoring for specific behaviors.

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During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

Correct Answer is A

Explanation

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2.

Which action(s) should the nurse take in response to these findings? (Select all that apply.)