Nokea
A nurse is reviewing the laboratory results on an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Blood glucose 100 mg/dL
- B. T4 11 mcg/dL
- C. Potassium 3.7 mEq/L
- D. Hgb 10 g/dL
Correct Answer: D
Rationale: The correct answer is D: Hgb 10 g/dL. In an adolescent with anorexia nervosa, low hemoglobin (Hgb) levels are expected due to malnutrition and inadequate intake of essential nutrients. Anorexia nervosa can lead to a deficiency in essential nutrients such as iron, which can result in anemia and low Hgb levels. This is a common finding in individuals with anorexia nervosa.
Blood glucose of 100 mg/dL (choice A) is within the normal range and not specific to anorexia nervosa. T4 of 11 mcg/dL (choice B) is also within the normal range and not typically affected by anorexia nervosa. Potassium of 3.7 mEq/L (choice C) is within the normal range and not a common finding in anorexia nervosa. Therefore, the correct answer is D as it is a common laboratory finding associated with anorexia nervosa.
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A nurse is providing teaching to a client who has bipolar disorder and a new prescription for lithium. Which of the following instructions should the nurse include?
- A. Take lithium on an empty stomach
- B. Avoid consuming foods high in sodium
- C. Drink 2-3 liters of water daily
- D. Increase caffeine intake
Correct Answer: C
Rationale: The correct answer is C: Drink 2-3 liters of water daily. Lithium is a mood stabilizer that can cause dehydration. Drinking an adequate amount of water helps prevent lithium toxicity and maintain proper kidney function. Choice A is incorrect because lithium should be taken with food to reduce gastrointestinal side effects. Choice B is incorrect because limiting sodium intake is not directly related to lithium therapy. Choice D is incorrect as increasing caffeine intake can lead to dehydration and worsen lithium side effects.
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
- A. Keep a journal of how often you check the locks each night
- B. Snap a rubber band on your wrist when you think about checking the locks
- C. Ask a family member to check the lock for you at night
- D. Focus on abdominal breathing whenever you go to check the locks
Correct Answer: B
Rationale: The correct answer is B: Snap a rubber band on your wrist when you think about checking the locks. This is an effective use of thought stopping technique as it creates a physical distraction and discomfort when the client has obsessive thoughts. It helps interrupt the pattern of behavior and redirects the client's focus away from the compulsion. Keeping a journal (A) may increase anxiety and reinforce the behavior. Asking a family member to check the lock (C) doesn't address the client's need to manage their own thoughts and behaviors. Focusing on abdominal breathing (D) may be a relaxation technique but doesn't directly address the obsessive thoughts.
A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?
- A. Request that the client’s partner sign the consent form
- B. Cancel the scheduled ECT procedure
- C. Proceed with the preparation for ECT based on implied consent
- D. Inform the client about the risks of refusing the ECT
Correct Answer: B
Rationale: The correct answer is B: Cancel the scheduled ECT procedure. The nurse must prioritize the autonomy and right to informed consent of the client. Since the client has verbally agreed but will not sign the consent form, it indicates uncertainty or potential coercion. Proceeding without proper documentation could lead to legal and ethical issues. Requesting the partner to sign (A) may not be ethically sound without the client's explicit consent. Proceeding based on implied consent (C) is risky and violates the client's autonomy. Informing the client about risks (D) is important but should not override the need for proper consent. Cancelling the procedure allows time for further discussion and ensures the client's best interest.
A nurse is assessing a client who has been taking clozapine for 3 months. Which of the following findings should the nurse report to the provider immediately?
- A. Constipation
- B. Sore throat
- C. Dry mouth
- D. Drowsiness
Correct Answer: B
Rationale: The correct answer is B: Sore throat. Clozapine can cause agranulocytosis, a serious condition characterized by a low white blood cell count, which can manifest as sore throat, fever, or flu-like symptoms. Immediate reporting is crucial to monitor for potential complications. Constipation (A), dry mouth (C), and drowsiness (D) are common side effects of clozapine but do not require immediate reporting unless severe.
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
- A. Place the client in a group therapy session
- B. Rotate staff members who work with the client
- C. Encourage the client to participate in physical activities
- D. Distract the client with increased environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to participate in physical activities. Physical activities can help to channel the excess energy and agitation associated with manic episodes in bipolar disorder. Exercise can help reduce stress, improve mood, and promote better sleep patterns. Group therapy (A) may not be appropriate during a manic episode as the client may have difficulty focusing and could disrupt the session. Rotating staff members (B) could lead to inconsistency in care and may worsen the client's symptoms. Distracting the client with increased environmental stimuli (D) could exacerbate agitation and overstimulation. It is important to provide a structured and safe outlet for the client's energy, hence physical activities are the most appropriate intervention in this scenario.