Nokea
The healthcare provider would expect which eating disorder to have the greatest fluctuations in potassium?
- A. Binge eating disorder
- B. Anorexia nervosa
- C. Bulimia
- D. Purge syndrome
Correct Answer: C
Rationale: The correct answer is C: Bulimia. Bulimia involves cycles of binge eating and purging, where individuals may induce vomiting or use laxatives and diuretics. These purging behaviors can lead to significant fluctuations in potassium levels due to electrolyte imbalances caused by excessive loss of potassium through vomiting and purging. In contrast, Binge eating disorder (A) does not involve purging behaviors, so it is less likely to cause significant potassium fluctuations. Anorexia nervosa (B) is characterized by severe food restriction rather than purging, leading to a different pattern of electrolyte imbalances. Purge syndrome (D) is not a recognized eating disorder and is not associated with specific patterns of potassium fluctuations seen in bulimia.
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The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
- A. Extreme fatigue
- B. Increased appetite
- C. Intense itching
- D. Constipation
Correct Answer: A
Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.
The nurse is caring for a 5-year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?
- A. Kicking balloons with the right leg
- B. Playing 'Simon Says'
- C. Playing handheld games
- D. Throwing bean bags
Correct Answer: C
Rationale: Playing handheld games is an appropriate diversional activity for a child in skeletal traction because it does not require physical movement of the affected limb. This activity can help keep the child entertained and engaged without risking any harm to the tractioned leg. Choices A, B, and D involve physical movements that could potentially interfere with the skeletal traction or cause discomfort to the child.
A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Hyperglycemia
- C. Gingival hyperplasia
- D. Hypokalemia
Correct Answer: C
Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.
A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
- A. Pain related to periosteal injury
- B. Impaired mobility related to bleeding
- C. Parental anxiety related to knowledge deficit
- D. Injury related to intracranial hemorrhage
Correct Answer: C
Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.
When assisting a family who fails to take action during a sick member despite suggestions, you will:
- A. explain the consequences of inaction
- B. identify the courses of action open to the family and the resources needed for each
- C. discuss the consequences of each course of action available
- D. influence the family to act on what you think is best for the situation
Correct Answer: B
Rationale: When helping a family decide on actions to take, it is essential to identify the courses of action available to them and the resources needed for each. This empowers the family to make informed decisions based on their specific situation. Explaining the consequences of inaction (Choice A) may be necessary but does not provide a range of options. Discussing the consequences of each course of action (Choice C) is important but does not actively guide the family on the available actions. Influencing the family (Choice D) to act based on personal judgment undermines their autonomy and may not lead to the best outcome.