Nurses' Notes

Client ate 80% of lunch with encouragement. Mild edema to hands, feet, and ankles. Client states, "It feels like my heart is jumping in my chest."

Graphic Results

BP 100/64 mm Hg

Pulse rate 58/min

Respiratory rate 16/min

Temperature 36.4° C (97.5° F)

SaO2 96%

BMI 16

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider?

Edema

Heart rhythm

Temperature

Intake

Answer and Explanation

The Correct Answer is B

A client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.

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Correct Answer is D

Explanation

Methylphenidate is a stimulant medication that is commonly used to treat attention-deficit hyperactivity disorder in children and adults. It helps improve attention, focus, and impulse control by increasing dopamine and norepinephrine levels in the brain. The other medications are not indicated for this condition.

A. Obtain the provider's prescription within 60 min. B. Document the client's behavior every 15 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who has a new diagnosis of attention-deficit hyperactivity disorder. The nurse should anticipate a prescription for which of the following medications?

Correct Answer is D

Explanation

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?

A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?

A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

A nurse is caring for a client who has been taking valproic acid. Which of the following is an expected outcome of the medication?