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A nurse is collecting data for a health history from a client who has bulimia nervosa. Which of the following laboratory findings should the nurse expect?
- A. Hypokalemia
- B. Leukopenia
- C. Decreased serum amylase
- D. Hematuria
Correct Answer: A
Rationale: Hypokalemia, or low potassium levels in the blood, is a common finding in individuals with bulimia nervosa, especially those who engage in frequent vomiting or use laxatives. Purging behaviors can lead to significant electrolyte imbalances, including potassium depletion, which can cause muscle weakness, cramps, and cardiac arrhythmias.
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A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?
- A. Unable to make simple decisions
- B. Enjoys spending time alone
- C. Exhibits extreme perfectionism
- D. Displays confrontational behavior
Correct Answer: A
Rationale: Individuals with dependent personality disorder often struggle with making simple decisions without excessive advice and reassurance from others. They have a strong need for others to take responsibility for major areas of their lives and can feel helpless when alone. This indecisiveness is a hallmark of the disorder and stems from their lack of self-confidence and reliance on others for guidance and support.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake, and I won't let it take all of my blood. Which of the following responses should the nurse make?
- B. Your provider requires this blood specimen.
- C. You must be mistaken. Snakes cannot be in the clinic.
- D. I'm using a syringe to obtain your blood, not a snake.
- E. I don't see a snake, but that must be scary for you.
Correct Answer: D
Rationale: Acknowledging the client's hallucination and expressing empathy is the most appropriate response. By saying, 'I don't see a snake, but that must be scary for you,' the nurse acknowledges the client's fear and provides comfort without reinforcing the hallucination. This approach helps build trust and rapport, making it easier to proceed with the necessary procedure while ensuring the client's emotional wellbeing.
A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?
- A. Serum creatinine.
- B. Thiamine level.
- C. Urinalysis.
- D. Erythrocyte sedimentation rate.
Correct Answer: B
Rationale: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.
A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?
- A. Determine whether the client's goals are met.
- B. Collect data about the client's current health status.
- C. Provide the client with information on problem-solving.
- D. Establish a regular meeting time with the client.
Correct Answer: C
Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.
A nurse is reinforcing teaching with a client who is scheduled for implantation of a vagus nerve stimulator. Which of the following statements should the nurse include in the teaching?
- A. You might have extreme fatigue for several weeks after the device is implanted.
- B. Your voice might sound hoarse after the device is implanted.
- C. Your depression will improve within 72 hours after the device is implanted.
- D. You can schedule an appointment with your provider to turn the device off.
Correct Answer: B
Rationale: Hoarseness or changes in voice is a common side effect after the implantation of a vagus nerve stimulator. The stimulator affects the vagus nerve, which is close to the vocal cords. As a result, stimulation can lead to changes in voice, including hoarseness. Patients should be informed of this potential side effect so they are not alarmed if it occurs.