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 ["A","B","D","E"]

Explanation

Hypotension, bradycardia, lanugo, and Russell's sign. Rationale: Hypotension and bradycardia are common manifestations of anorexia nervosa due to dehydration, electrolyte imbalance, and decreased cardiac output. Lanugo is fine hair that covers the body as a result of decreased body fat and thermoregulation. Russell's sign is calluses or scars on the knuckles or hands from self-induced vomiting. Diarrhea is not a typical finding of anorexia nervosa.

A. "How have you dealt with stress in the past?" B. "Are you thinking of harming yourself?" C. "Let's talk more about what you are experiencing." D. "Tell me what makes you feel stressed."

Correct Answer is B

Explanation

The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia. The client's employer calls to discuss the client's condition. Which of the following is the appropriate nursing action?

A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory results should the nurse report to the provider?

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 nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?

A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan?

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?

A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?