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A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?
- A. Lanugo.
- B. Muscle wasting.
- C. Hypokalemia.
- D. Hypomagnesemia.
Correct Answer: C
Rationale: Hypokalemia, low potassium levels, is a common finding in bulimia nervosa due to repeated vomiting and laxative use. These behaviors lead to significant electrolyte imbalances, posing serious health risks.
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A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?
- A. I can encourage my child to think about what they did that allowed this event to happen.
- B. I anticipate that my child will feel some self-blame.
- C. I should encourage my child to focus solely on the future.
- D. I will have to do all I can to monitor my child's relationships.
Correct Answer: D
Rationale: Actively monitoring the adolescent's relationships can demonstrate vigilance and support, helping to create a safe environment for recovery. This shows a proactive, protective stance, indicative of a positive support system.
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 collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?
- A. Fluctuating level of orientation.
- B. Consistent state of depression.
- C. Demonstrates obsessive behaviors.
- D. Short-term memory loss.
Correct Answer: A
Rationale: A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention and cognition, distinguishing it from depression or dementia.
A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?
- A. Making a unit calendar to promote orientation.
- B. Discussing childhood memories during group therapy.
- C. Encouraging thought-stopping to block undesirable thoughts.
- D. Playing board games with other clients to enhance cognition.
Correct Answer: B
Rationale: Discussing childhood memories fosters reminiscence, aiding in cognitive stimulation and emotional connection among older adults. This aligns with the goals of reminiscence therapy, unlike orientation aids or thought-stopping.
A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?
- A. Request a consult with recreational therapy.
- B. Lower the window shade in the client's room.
- C. Place the client in a room close to the nurses' station.
- D. Obtain a PRN prescription for a vest restraint.
Correct Answer: C
Rationale: Placing the client near the nurses' station allows for closer monitoring and quicker intervention, which can help prevent falls. This is a practical, non-restrictive measure to enhance safety.