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A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- B. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- C. People who have bulimia nervosa eat an average amount of food on a daily basis.
- D. As long as a person is not vomiting after eating, they do not have bulimia nervosa.
Correct Answer: B
Rationale: Individuals with bulimia nervosa often maintain an average or ideal body weight, making the disorder less visible. This highlights a key characteristic for community education.
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A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?
- A. Receiving light therapy.
- B. Taking an experimental medication.
- C. Participating in a group exercise program.
- D. Attending a cognitive behavioral therapy class.
Correct Answer: B
Rationale: Experimental medications require informed consent due to the potential unknown effects and risks. Ensuring the client is fully informed about the experimental nature and possible side effects is crucial, unlike routine interventions like light therapy or therapy classes.
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.
Nurses' Notes
0800: Client is 3 days postoperative. Currently disoriented to time and place, oriented to self. Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times. Client attempts to get out of bed without assistance. Changes in client's behavior began the prior evening and client has been awake most of the night. Client has refused to eat or drink since the previous day. Intake and output from previous day: 250 mL intake, 2,500 mL output. Call placed to provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per provider's prescription. Client continues to be restless.
Vital Signs
• Heart rate: 115/min
• Respiratory rate: 20/min
• Blood pressure: 90/65 mm Hg
• Temperature: 38.6°C (101.5°F)
A nurse is caring for an older adult client who is postoperative.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 arameters the nurse should monitor to collect data about the client's progress.
- A. Delirium,Depression,Alzheimer's disease,Generalized anxiety disorder
- B. Encourage family members to stay with the client,Assist the client to identify coping skills,Monitor the client's fluid intake and output,Encourage the client to exercise.
- C. Suicidal ideation,Weight loss,Fall risk,Sleep-wake cycle
Correct Answer: A
Rationale: Delirium fits acute postoperative confusion. Family presence reassures, fluid monitoring addresses dehydration, and tracking fall risk and sleep assess safety and recovery.
A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?
- A. Place a lock at the top of doors leading outside.
- B. Use light restraints while the client is in bed.
- C. Administer an antianxiety medication before bedtime.
- D. Encourage the client to nap during the day.
Correct Answer: A
Rationale: Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety. This is a practical, non-restrictive measure to manage nighttime wandering in Alzheimer’s.
A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2.5
Rationale: Step 1: (50 mg ÷ 20 mg/mL) × 1 mL = 2.5 mL. The nurse should administer 2.5 mL to deliver the prescribed 50 mg dose, calculated based on the concentration of the available solution.