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A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Constipation
- C. Menorrhagia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Constipation. In anorexia nervosa, a lack of adequate nutrition intake can lead to decreased gastrointestinal motility, resulting in constipation. Tachycardia (A) is common due to the body's response to malnutrition. Menorrhagia (C) is unlikely as anorexia nervosa often leads to amenorrhea. Hyperkalemia (D) is less likely as potassium levels tend to be low due to decreased food intake.
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A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?
- A. "I can arrange for a female assistive personnel to do your personal hygiene care."
- B. "The nurse assigned to care for you is very capable and cares for other women in this situation."
- C. "Your doctor is a man, so it seems like this should not be a problem."
- D. "I can review the assignments and arrange for a female nurse to care for you."
Correct Answer: D
Rationale: The correct answer is D. The nurse manager should respect the client's wishes and arrange for a female nurse to care for her. This is important for the client's comfort and sense of safety. Option A only addresses personal hygiene care, not overall nursing care. Option B focuses on the nurse's capabilities, not the client's preferences. Option C is dismissive of the client's concerns and does not address the issue directly. It is essential to prioritize the client's feelings and choices in this sensitive situation.
A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
- A. "Perhaps you should discuss this with your physician."
- B. "Of course you aren't going to die, at least not in the immediate future."
- C. "I recommend you exercise daily and avoid smoking to decrease your risk."
- D. "Tell me more about these fears of dying from a heart attack."
Correct Answer: D
Rationale: Encouraging the client to talk about their fears fosters therapeutic communication.
A nurse is assigning a room to a client who is experiencing a manic episode. Which of the following is the most appropriate room selection?
- A. A room adjacent to the nursing station
- B. A room without a window
- C. A room with dim lighting
- D. A room containing personal belongings
Correct Answer: A
Rationale: A room close to the nursing station allows for close monitoring and quick intervention if necessary.
A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.” Which of the following findings is this client exhibiting?
- A. Flight of ideas
- B. Grandiosity
- C. Impaired reality testing
- D. Depersonalization
Correct Answer: B
Rationale: The correct answer is B: Grandiosity. The client's belief that they can do anything, like flying and becoming a U.S. Senator, reflects grandiosity, a symptom of bipolar disorder's manic phase. This is characterized by an inflated sense of self-importance and abilities. Flight of ideas (A) is a rapid shifting of thoughts, not seen in this scenario. Impaired reality testing (C) involves difficulty distinguishing between reality and fantasy; this client is not questioning reality. Depersonalization (D) is feeling detached from oneself, not demonstrated here.
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?
- A. Lock the doors to the unit and secure windows so they cannot be opened.
- B. Provide the client with plastic eating utensils for meals.
- C. Remove any objects from the client's environment that could be used for self-harm.
- D. Assign a staff member to stay with the client at all times.
Correct Answer: D
Rationale: A client who refuses a safety contract is at high risk, requiring constant supervision to ensure safety.