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A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Cold extremities.
- B. Diarrhea.
- C. Tooth erosion.
- D. Lanugo.
Correct Answer: A,C,D
Rationale: Cold extremities, tooth erosion, and lanugo are common in anorexia nervosa. Poor circulation causes cold extremities, vomiting erodes teeth, and lanugo grows to conserve heat due to fat loss, reflecting the disorder’s physical impact.
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A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?
- A. Everyone feels depressed during the grieving process.
- B. I remember how depressed I was after my friend died.
- C. You should start participating in your usual activities.
- D. Tell me what your relationship with your partner was like.
Correct Answer: D
Rationale: Asking about the client’s relationship encourages them to express their feelings and helps the nurse understand their experience to provide support. This fosters a therapeutic dialogue.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?
- A. Discuss the benefits of relaxation exercises with the client.
- B. Explain the use of response prevention to the client.
- C. Administer an antianxiety medication.
- D. Calculate the client's score on the Hamilton Rating Scale for Anxiety.
Correct Answer: D
Rationale: Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions. This baseline data collection is the priority upon admission to tailor subsequent care.
A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?
- A. Bupropion.
- B. Risperidone.
- C. Aripiprazole.
- D. Quetiapine.
Correct Answer: A
Rationale: Bupropion is an antidepressant also used to aid smoking cessation by reducing cravings and withdrawal symptoms. It’s specifically indicated for this purpose.
A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. Currently married.
- B. Access to guns in the home.
- C. Terminal liver cancer.
- D. Alcohol use disorder.
Correct Answer: B,C,D
Rationale: Access to guns in the home, terminal liver cancer, and alcohol use disorder are significant risk factors for suicide. Guns increase lethality, terminal illness causes distress, and alcohol impairs judgment and increases impulsivity, all elevating suicide risk.
A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?
- A. Implement 24-hr one-to-one nursing observation.
- B. Document the client's behavior every 2 hr.
- C. Restrict interactions with other clients.
- D. Administer prescribed medication via the IM route.
Correct Answer: A
Rationale: Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm. This provides constant monitoring given the high-risk situation.