Nokea
A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?
- A. Ask the client to complete a food diary for the last 3 days
- B. Review the client's lab data to determine her TSH, T3, and T4 levels
- C. Interview the client about her use of laxatives and diuretics
- D. Encourage the client to describe her daily exercise regimen
Correct Answer: C
Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.
You may also like to solve these questions
When the client asks the nurse if they have ever been with someone when they died, what is the nurse's best response?
- A. "Yes, I have. Do you have some questions about dying?"
- B. "Several times. Now, let's get your dressing changed."
- C. "A few times. It was peaceful and there was no pain."
- D. "Yes, but you're doing great. Are you concerned about dying?"
Correct Answer: A
Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.
After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?
- A. Observe the aspiration site
- B. Assess body temperature
- C. Monitor skin elasticity
- D. Measure urinary output
Correct Answer: A
Rationale: The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.
The healthcare provider changes a client's medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduces bioavailability. What action should the nurse implement?
- A. Continue administering the medication via the IV route.
- B. Give half the prescribed oral dose until consulting the provider.
- C. Administer the medication orally as prescribed.
- D. Consult with the pharmacist regarding the prescription change.
Correct Answer: D
Rationale: The correct action for the nurse to implement is to consult with the pharmacist regarding the change in prescription. With the high first-pass effect of the medication when given orally, it reduces its bioavailability, meaning a dosage adjustment may be necessary to achieve the desired therapeutic effect. Continuing to administer the medication via the IV route (choice A) is not appropriate as the prescription has been changed to oral administration. Giving half the prescribed oral dose until consulting the provider (choice B) is not recommended without proper guidance, which should come from consulting with the pharmacist. Simply administering the medication orally as prescribed (choice C) without addressing the potential issue of reduced bioavailability may lead to suboptimal treatment outcomes.
An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?
- A. Have both nurses meet separately with the staff mental health consultant
- B. Listen actively to both nurses and offer suggestions to solve the dilemma
- C. Ask the senior nurse to examine mentoring strategies used with the new graduate
- D. Ask the nurses to meet with the nurse-manager to identify ways of working together
Correct Answer: D
Rationale: In this scenario, the best action for the nurse manager to take is to ask the nurses to meet with the nurse-manager to identify ways of working together. This approach promotes open communication, facilitates understanding of both perspectives, and encourages collaborative problem-solving. Option A is not ideal as involving a mental health consultant may be premature for this situation. Option B, although helpful in listening to both parties, does not directly address the need for collaboration. Option C focuses on the senior nurse's mentoring strategies only, rather than addressing the conflict between the two nurses.
A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?
- A. Determine serum potassium level
- B. Calculate the client's daily fluid intake
- C. Assess client for signs of vertigo
- D. Review the client's pulse oximetry reading
Correct Answer: A
Rationale: The correct answer is to determine the client's serum potassium level. In a client with renal disease experiencing symptoms like shortness of breath, lethargy, edema, and weight gain, assessing serum potassium levels is crucial. Electrolyte imbalances, including potassium, can lead to serious complications such as cardiac arrhythmias and muscle weakness. Calculating daily fluid intake may be important but addressing acute symptoms related to electrolyte imbalances takes precedence. Assessing for signs of vertigo and reviewing pulse oximetry reading are not the priority in this scenario compared to assessing and managing potential electrolyte imbalances.