Nokea
The nurse is caring for a client with anorexia nervosa. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Heat intolerance
- B. Has not menstruated in 3 months
- C. Avoids participation in physical activity
- D. Fine, downy hair on the face and back
- E. Decreased serum potassium level
- F. BMI of 16 kg/m²
Correct Answer: B,D,E,F
Rationale: Anorexia nervosa is characterized by severe weight loss and malnutrition, leading to specific clinical findings. Amenorrhea (B) results from hormonal imbalances due to low body fat. Lanugo (D), fine downy hair, develops as a compensatory mechanism for heat loss. Hypokalemia (E) occurs due to starvation or purging behaviors. A BMI of 16 kg/m² (F) indicates severe underweight status, consistent with anorexia. Heat intolerance (A) is more typical of hyperthyroidism, and avoiding physical activity (C) is incorrect as clients often engage in excessive exercise.
You may also like to solve these questions
The nurse is talking with a client with macular degeneration. Which of the following statements by the client would be consistent with the condition?
- A. I have been seeing small flashes of light in one eye.
- B. I noticed that my peripheral vision is becoming worse.
- C. I see a blurry spot in the middle of the page when I read.
- D. I cannot see the newspaper unless I hold it away from me.
Correct Answer: C
Rationale: Macular degeneration affects central vision, causing a blurry or dark spot in the visual field, as described in (C), due to damage to the macula. Flashes of light (A) suggest retinal issues, peripheral vision loss (B) is typical of glaucoma, and difficulty reading up close (D) relates to presbyopia.
A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?
- A. Blurred vision
- B. Dark-colored urine
- C. Difficulty hearing
- D. Yellow skin
Correct Answer: A
Rationale: Ethambutol can cause optic neuritis, leading to blurred vision (A), a serious side effect requiring immediate reporting. Dark urine (B), hearing loss (C), and jaundice (D) are associated with other TB drugs (e.g., rifampin, isoniazid).
The nurse is reinforcing teaching of proper foot care to a client with diabetes mellitus. Which statement by the client indicates the need for further teaching?
- A. I will apply lanolin to my feet to prevent dry skin
- B. I will avoid applying a heating pad directly to my feet
- C. I will test the water with a thermometer before bathing
- D. I will wear sandals instead of sneakers to prevent moisture.
Correct Answer: D
Rationale: Sandals (D) expose feet to injury, increasing infection risk in diabetes. Lanolin (A), avoiding heating pads (B), and testing water (C) are correct to prevent skin breakdown and burns.
A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
- A. Blood pressure 94/60
- B. Heart rate 76 BPM
- C. Urine output 50 ml/hour
- D. Respiratory rate 16
Correct Answer: A
Rationale: Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both medications.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish her supply every three months.
- B. Take one every 15 minutes if pain occurs.
- C. Leave the medication in the brown bottle.
- D. Crush the medication and take it with water.
Correct Answer: C
Rationale: The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.