Exhibits

Complete the diagram by dragging from the choices area to specify condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Anorexia Nervosa

The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.

Actions the Nurse Should Take:

Educate on the condition:

The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.

Acknowledge anxious feelings:

The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.

Parameters to Monitor:

Weight:

Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.

Achievement of 100% of ideal weight:

Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.

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Correct Answer is B

Explanation

A. While assessing skin condition is important, the priority in this case is managing fluid balance, especially after surgery.

B. Replacing fluids intravenously based on intake and output is crucial to ensure the client is adequately hydrated and to prevent complications related to fluid loss, particularly after surgery for ulcerative colitis. This is vital in maintaining homeostasis and promoting healing.

C. Recording the amount of wound drainage is important for monitoring healing, but it is secondary to managing fluid balance postoperatively.

D. Turning the client every 2 hours is important for preventing pressure injuries, but in this context, ensuring proper fluid management takes precedence.

A. Complete blood cell count (CBC) in AM. B. Straight catheterization if unable to void. C. Advance from clear liquids as tolerated. D. Cefazolin 1 gram intravenously every 6 hours.

Correct Answer is B

Explanation

A. A complete blood cell count (CBC) is important for monitoring but is not an immediate priority during the admission process.

B. Straight catheterization if unable to void is a priority intervention to prevent bladder distention and complications following surgery.

C. Advancing from clear liquids as tolerated can be important for nutrition but does not address immediate postoperative concerns regarding urinary function.

D. Administering Cefazolin is important for preventing infection but should be prioritized after ensuring the client can void or addressing any issues with urinary retention.

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Exhibits Complete the diagram by dragging from the choices area to specify condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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Exhibits

Complete the diagram by dragging from the choices area to specify condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse to assess the client's progress.