Nokea
A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, 'I haven't exercised in 6 days. I won't be eating lunch today.' This statement by her most likely reflects:
- A. Her lack of internal awareness about the outcome of the behavior
- B. Increased knowledge about personal exercise plans
- C. A manipulative technique to trick the nurse into allowing her to miss a meal
- D. A true desire to stay fit while in the hospital
Correct Answer: A
Rationale: Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client's lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted.
You may also like to solve these questions
A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
- A. Monitoring the chest tubes
- B. Positioning the client on the right side
- C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
- D. Monitoring the right lung for an increase in rales
Correct Answer: D
Rationale: Monitoring the right lung for an increase in rales is essential to detect early signs of fluid accumulation or infection in the remaining lung.
The nurse is caring for a client with a history of anaphylaxis to peanuts. Which precaution is most important?
- A. Keep an epinephrine auto-injector at the bedside.
- B. Place the client in a private room.
- C. Administer antihistamines daily.
- D. Monitor for respiratory distress every 4 hours.
Correct Answer: A
Rationale: An epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Private rooms, antihistamines, and monitoring are secondary to ensuring rapid emergency response.
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.
Which of the following signs might indicate a complication during the labor process with vertex presentation?
- A. Fetal tachycardia to 170 bpm during a contraction
- B. Nausea and vomiting at 8-10 cm dilation
- C. Contraction lasting 60 seconds
- D. Appearance of dark-colored amniotic fluid
Correct Answer: D
Rationale: Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. Nausea and vomiting occur frequently during transition and are not a complication. Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
- A. Encourage exercises in the unaffected extremities.
- B. Encourage her to cross and uncross her legs.
- C. Check neurological and circulatory status of the affected leg hourly.
- D. Place a trochanter roll along the upper thigh of the affected leg.
Correct Answer: B
Rationale: Exercising the unaffected extremities will prevent contractures and emboli. Crossing and uncrossing the affected leg after surgery can dislocate the joint. Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.