The nurse continues to care for the client

Exhibits

The nurse is discussing the plan of care with the client. Select the 3 statements the nurse should make.

"We will create an exercise plan once you reach your target weight."

"We will monitor your blood pressure every other day until it is stable."

"We would like you to eat independently to limit distractions during mealtime."

"We will explore your thoughts that trigger you to participate in a rigorous exercise regimen."

"We will weigh you every evening to monitor your progress."

"We will set a goal for you to gain 2 to 3 pounds per week."

Answer and Explanation

Correct Answer : A,D,F

A. "We will create an exercise plan once you reach your target weight." Clients with anorexia nervosa often engage in excessive exercise to maintain low body weight. Exercise should be restricted until the client reaches a safe weight to prevent further calorie deficits and medical complications. Once the client is nutritionally stable, a structured exercise plan can be introduced in a healthy and controlled manner.
B. "We will monitor your blood pressure every other day until it is stable." Blood pressure should be monitored daily or more frequently due to the client's hypotension (89/58 mmHg), malnutrition, and electrolyte imbalances. Monitoring it every other day is insufficient for assessing cardiovascular stability.
C. "We would like you to eat independently to limit distractions during mealtime." Clients with anorexia nervosa often need supervision during meals to ensure they are consuming adequate nutrition and not engaging in maladaptive behaviors such as food restriction, hiding food, or cutting food into tiny pieces. Independent eating is not appropriate at this stage of treatment.
D. "We will explore your thoughts that trigger you to participate in a rigorous exercise regimen." Clients with anorexia often use excessive exercise as a form of control or calorie compensation. Addressing these thoughts through therapy and cognitive-behavioral strategies is essential in promoting healthier behaviors.
E. "We will weigh you every evening to monitor your progress." Weighing should be done once daily at the same time each morning, preferably before breakfast and after urination, to ensure consistent and accurate measurements. Frequent weigh-ins may increase anxiety and obsession over weight fluctuations, making evening weigh-ins inappropriate.
F. "We will set a goal for you to gain 2 to 3 pounds per week." A weight gain of 2 to 3 pounds per week is a standard goal in the nutritional rehabilitation of clients with anorexia nervosa. A gradual and structured weight gain process prevents refeeding syndrome and promotes safe recovery.

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Correct Answer is D

Explanation

A. Urinary retention. While urinary retention can occur with both diazepam (a benzodiazepine) and hydromorphone (an opioid) due to their effects on the nervous system, it is not immediately life-threatening. This side effect should be monitored and managed, but it is not the priority concern.
B. Blurred vision. Blurred vision is a possible side effect of both medications, particularly diazepam, which can cause central nervous system (CNS) depression. However, it is not as critical as respiratory depression, which can be fatal if left untreated.
C. Headache. Headaches are a less serious side effect and do not indicate an urgent risk to the client’s safety. Other symptoms, such as bradypnea, should take precedence in immediate care.
D. Bradypnea. Respiratory depression is the most serious concern when benzodiazepines and opioids are used together. Both medications depress the CNS and can lead to severe respiratory compromise, coma, or even death. Bradypnea (slow breathing) is a priority finding because it indicates a potential overdose or dangerously suppressed respiratory drive, requiring immediate medical intervention.

A. The client has a serotonin deficiency. B. The client has acute bronchitis C. The client has an elevated calcium level D. The client is an only child.

Correct Answer is A

Explanation

A. The client has a serotonin deficiency. Serotonin plays a crucial role in mood regulation, and low levels of serotonin are strongly associated with major depressive disorder (MDD). This neurotransmitter imbalance contributes to symptoms such as persistent sadness, low energy, and disrupted sleep patterns. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to increase serotonin levels and alleviate depressive symptoms.
B. The client has acute bronchitis. While physical illnesses can impact mood, acute bronchitis is a temporary respiratory infection that does not directly cause major depressive disorder. Chronic illnesses may contribute to depression, but acute conditions are not considered significant risk factors.
C. The client has an elevated calcium level. Hypercalcemia can cause fatigue, confusion, and depression-like symptoms, but it is a medical condition rather than a primary cause of MDD. Treating the underlying cause of hypercalcemia usually resolves mood-related symptoms.
D. The client is an only child. Birth order and family size have no direct biological or psychological link to MDD. While loneliness or social factors can influence mental health, being an only child is not considered a risk factor for major depressive disorder.

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The nurse continues to care for the client Exhibits The nurse is discussing the plan of care with the client. Select the 3 statements the nurse should make.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A mental health nurse is providing preventive care for a group of clients in the community. Which of the following actions by the nurse demonstrates a secondary prevention strategy?

The nurse continues to care for the client

Exhibits

The nurse is discussing the plan of care with the client. Select the 3 statements the nurse should make.