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A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?
- A. Provide a supportive, structured environment for meals.
- B. Assess weight, vital signs, potassium, and other electrolytes.
- C. Discuss alternative strategies for binging and purging.
- D. Monitor the client after meals for possible vomiting.
Correct Answer: B
Rationale: Assessing weight, vital signs, and electrolytes is critical to identify life-threatening complications of bulimia, taking precedence over other interventions.
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The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?
- A. Vomiting, seizures, and loss of consciousness.
- B. Agitation, sweating, and abdominal cramps.
- C. Depression, fatigue, and dizziness.
- D. Hypotension, shallow respirations, and dilated pupils.
Correct Answer: B
Rationale: Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal, consistent with opioid use suggested by needle marks.
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease.
- B. Familial history of mental illness.
- C. Current weight.
- D. Medication history.
Correct Answer: D
Rationale: Medication history is critical to identify potential drug interactions, especially with serotonergic drugs, to prevent serotonin syndrome. Heart disease history, familial mental illness, and weight are relevant but secondary. [Note: Document incorrectly lists A as correct; D is more appropriate per standard practice.]
A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
- A. Ask the client why she checks the locks.
- B. Determine the type and size of the locks.
- C. Discuss checking the time frequently.
- D. Plan a list of activities to be carried out daily.
Correct Answer: D
Rationale: Planning daily activities redirects focus from compulsive checking, reducing anxiety and improving function, suitable for OCD-like behaviors.
History and Physical
Initial vital signs:
Imaging Studies
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD).
She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis.
The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client.
- A. Monitor cardiac status
- B. Educate on dialysis compliance
- C. Monitor vital signs
- D. Perform head-to-toe assessment
- E. Monitor heart rhythm
- F. Monitor fluid intake and output
- G. Monitor neuromuscular status
Correct Answer: A,B,C,D,E,F,G
Rationale: Monitoring cardiac status, vital signs, heart rhythm, fluid balance, and neuromuscular status, along with educating on dialysis compliance and low-potassium diet, are essential for managing ESRD and hyperkalemia. Transfer to telemetry is not indicated with stable vitals.