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The nurse reviews the Nurses' Notes from Day 1 at 1100.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for correct choices:

  • Electrolyte imbalance: The client’s potassium level of 3.0 mEq/L is critically low, contributing to premature ventricular contractions and orthostatic hypotension. These abnormalities place the client at immediate risk for cardiac dysrhythmias and require urgent correction to prevent life-threatening complications.
  • View of body: The client voices fear of gaining weight and fixates on food, which are indicators of distorted self-perception. This impaired view of the body is a central feature of bulimia nervosa and needs to be addressed during psychotherapy once the client is medically stabilized.

Rationale for incorrect choices:

  • Impaired body image: While body image concerns are common in eating disorders, this option is more general. “View of body” better captures the client’s psychological distortion and allows for more precise therapeutic interventions that address the cognitive roots of the disorder.
  • Impaired coping: The client engages in maladaptive coping strategies like bingeing and purging. However, these behaviors are secondary to deeper distortions in self-image and medical instability. Coping can be addressed later in the treatment process once safety is ensured.
  • History of anxiety: Anxiety is part of the client's long-standing history but is not causing the immediate physical risk. Addressing acute electrolyte disturbances and body image distortion takes precedence over chronic anxiety in this clinical setting.
  • Obsession with food: Although the client’s persistent thoughts about food are important, they are symptoms driven by distorted body perception. Treating the underlying belief system about body image is more foundational and effective in resolving food-related obsessions.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. The nurse explained the risks and benefits of the surgery: Explaining the risks and benefits of a surgical procedure is the responsibility of the surgeon, not the nurse. The nurse may clarify or reinforce information but does not provide the primary explanation.

B. The nurse explained the surgical procedure in detail: Nurses can offer general clarification, but it is the surgeon’s legal and ethical duty to explain the procedure in detail, including alternatives, risks, and benefits, as part of obtaining informed consent.

C. The client knows they may no longer refuse the procedure: Clients have the legal right to refuse a procedure at any time, even after signing consent. Consent is not binding and must remain voluntary and revocable until the procedure begins.

D. The client agreed to the procedure voluntarily: Informed consent requires that the client makes the decision freely, without coercion. Observing the client voluntarily agree to the procedure meets this core legal and ethical requirement of informed consent.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B"},"D":{"answers":"A,B,C"}}

Explanation

Rationale:

  • Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
  • Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
  • Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.
  • Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.

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